Current options for nonsurgical management of carpal tunnel syndrome

A Retrospective Comparison of Conventional versus Transverse Mini-Incision Technique for Carpal Tunnel Release

Background. In this retrospective study, we aimed to compare the results of two surgical techniques, conventional and transverse mini-incision. Materials and Methods. 95 patients were operated between 2011 and 2012 in Bitlis State Hospital. 50 patients were operated with conventional technique and 45 of them were operated with minimal transverse incision. Postoperative complications, incision site problems, and the time of starting to use their hands in daily activities were noted. Results. 95 patients were included in the study. The mean age was 48. 87 of them were female and 8 were male. There was no problem of incision site in both of the two surgical techniques. Only in one patient, anesthesia developed in minimal incision technique. The time of starting to use their hands in daily activities was 22,2 days and 17 days in conventional and minimal incision technique, respectively. Conclusion. Two surgical techniques did not show superiority to each other in terms of postoperative complications and incision site problems except the time of starting to use their hands in daily activities.

Ultrasound for diagnosis of carpal tunnel syndrome: comparison of different methods to determine median nerve volume and value of power Doppler sonography

OBJECTIVE

To compare ultrasound measurement of median nerve cross-sectional area (CSA) at different anatomical landmarks and to assess the value of power Doppler signals within the median nerve for diagnosis of carpal tunnel syndrome (CTS).

METHODS

A prospective study of 135 consecutive patients with suspected CTS undergoing two visits within 3 months. A final diagnosis of CTS was established by clinical and electrophysiological findings. CSA was sonographically measured at five different levels at forearm and wrist; and CSA wrist to forearm ratios or differences were calculated. Intraneural power Doppler signals were semiquantitatively graded. Diagnostic values of different ultrasound methods were compared by receiver operating characteristic curves using SPSS.

RESULTS

CTS was diagnosed in 111 (45.5%) wrists; 84 (34.4%) had no CTS and 49 (20.1%) were possible CTS cases. Diagnostic values were comparable for all sonographic methods to determine median nerve swelling, with area under the curves ranging from 0.75 to 0.85. Thresholds of 9.8 and 13.8 mm(2) for the largest CSA of the median nerve yielded a sensitivity of 92% and a specificity of 92%. A power Doppler score of 2 or greater had a specificity of 90% for the diagnosis of CTS. Sonographic median nerve volumetry revealed a good reliability with an intraclass correlation coefficient of 0.90 (95% CI 0.79 to 0.95).

CONCLUSIONS

Sonographic assessment of median nerve swelling and vascularity allows for a reliable diagnosis of CTS. Determination of CSA at its maximal shape offers an easily reproducible tool for CTS classification in daily clinical practice.

Color Doppler ultrasound for evaluation of vasomotor activity in patients with carpal tunnel syndrome

BACKGROUND

Patients with carpal tunnel syndrome (CTS) have a variety of vasomotor symptoms. Here, we aimed to study the vasomotor activity of the radialis indicis (RI) artery (median nerve territory) and the radial palmar digital (RPD) artery of the little finger (ulnar nerve territory) before and after sympathetic stimulation in CTS patients using color Doppler ultrasound.

METHODS

We performed a cross-sectional study of 46 consecutive CTS patients plus 36 healthy controls. All patients underwent electromyography studies and were classified into mild and moderate/severe groups according to electrodiagnostic findings. Color Doppler examination of the RI artery and the RPD artery of the little finger were performed with the participants in a relaxed sitting position and after a deep breath followed by a cough (sympathetic stimulation). The pulsatility index (PI) was recorded at the point of maximal change in waveform, before and after this stimulus.

RESULTS

The PI of RI artery was significantly lower (p < 0.01) in CTS patients than healthy controls, both before and after stimulation. The changes in PI of RI artery after stimulation were significantly lower in CTS patients than healthy controls (1.18 ± 0.37 vs. 5.41 ± 0.87; p < 0.001). The same pattern was seen for PI of RI artery when comparing patients with mild vs. moderate/severe CTS. No difference was found in PI of RPD artery of the 5th finger between patients vs. controls and between patients with mild vs. moderate/severe CTS, both before and after stimulation.

CONCLUSIONS

We showed that color Doppler ultrasound can readily determine impaired vasomotor activity in CTS patients.

Clinical trial of the p38 MAP kinase inhibitor dilmapimod in neuropathic pain following nerve injury

Current treatments of neuropathic pain arising from conditions such as nerve injury/compression are only partially effective, and limited in their use by side-effects. p38 mitogen-activated protein kinase (MAPK) is involved in the regulation and synthesis of inflammatory mediators, and is the target for a novel class of cytokine-suppressive anti-inflammatory drugs. p38 inhibitors may reduce neuronal sensitisation in preclinical models of neuropathic pain, particularly where there is a substantial inflammatory component. An exploratory, multicentre, double-blind, placebo-controlled, two-period, cross-over trial was undertaken to evaluate the effect of dilmapimod (SB-681323), a selective p38 MAPK inhibitor, on neuropathic pain symptoms and signs. Fifty patients with nerve trauma, radiculopathy or carpal tunnel syndrome were randomised; 43 patients completed the study. Eligible patients received oral dilmapimod and placebo twice daily for 2 weeks, with an intervening washout period of 2-4 weeks. Subjects attended weekly for efficacy and safety assessments, which included evaluation of daily and current pain intensity using an 11-point numerical rating scale (NRS), quantitative sensory testing, allodynia and global impression of change. There was a statistically significant reduction in the primary endpoint of average daily pain score during the second week of treatment among patients treated with dilmapimod (15 mg/day) compared to placebo using NRS [0.80; 95% CI (0.28, 1.33); p=0.0034]. A similar trend for effect was seen in some secondary endpoints. Dilmapimod was well tolerated, with no clinically relevant safety findings. p38 MAPK inhibitors merit further evaluation for neuropathic pain in larger clinical trials, particularly for clinically meaningful analgesic effect size.