Neurophysiological recovery 5 years after carpal tunnel release in patients with diabetes

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder worldwide. The epidemiology and risk factors, including family burden, for developing CTS are multi-factorial. Despite much research, its intricate pathophysiological mechanism(s) are not fully understood. An underlying subclinical neuropathy may indicate an increased susceptibility to developing CTS. Although surgery is often performed for CTS, clear international guidelines to indicate when to perform non-surgical or surgical treatment, based on stage and severity of CTS, remain to be elucidated. Neurophysiological examination, using electrophysiology or ultrasonography, performed in certain circumstances, should correlate with the history and findings in clinical examination of the person with CTS. History and clinical examination are particularly relevant globally owing to lack of other equipment. Various instruments are used to assess CTS and treatment outcomes as well as the effect of the disorder on quality of life. The surgical treatment options of CTS - open or endoscopic - offer an effective solution to mitigate functional impairments and pain. However, there are risks of post-operative persistent or recurrent symptoms, requiring meticulous diagnostic re-evaluation before any additional surgery. Health-care professionals should have increased awareness about CTS and all its implications. Future considerations of CTS include use of linked national registries to understand risk factors, explore possible screening methods, and evaluate diagnosis and treatment with a broader perspective beyond surgery, including psychological well-being.

Carpal Tunnel Syndrome and Diabetes—A Comprehensive Review

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the general population and is frequently encountered among individuals with type 1 and 2 diabetes. The reason(s) why a peripheral nerve trunk in individuals with diabetes is more susceptible to nerve compression is still not completely clarified, but both biochemical and structural changes in the peripheral nerve are probably implicated. In particular, individuals with neuropathy, irrespective of aetiology, have a higher risk of peripheral nerve compression disorders, as reflected among individuals with diabetic neuropathy. Diagnosis of CTS in individuals with diabetes should be carefully evaluated; detailed case history, thorough clinical examination, and electrophysiological examination is recommended. Individuals with diabetes and CTS benefit from surgery to the same extent as otherwise healthy individuals with CTS. In the present review, we describe pathophysiological aspects of the nerve compression disorder CTS in relation to diabetes, current data contributing to the explanation of the increased risk for CTS in individuals with diabetes, as well as diagnostic methods, treatment options, and prognosis of CTS in diabetes.

Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

INTRODUCTION

Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment.

PURPOSE OF THE STUDY

This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients.

METHODS

Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements.

RESULTS

Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist-middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = -4.31, 95% CI = -5.89 to -2.74, P < .001 and MD = -2.74, 95% CI = -5.32 to -0.16, P = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies.

CONCLUSION

Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.

Outcome of carpal tunnel release in patients with normal nerve conduction studies

BACKGROUND

We evaluated outcome after carpal tunnel release (CTR) in patients with clinically diagnosed carpal tunnel syndrome (CTS) but normal results in nerve conduction studies (NCS), and compared these results with those from a prospective group of patients with NCS-verified CTS.

METHODS

Over a 5-year period, we prospectively included 103 patients with clinical CTS. NCS were done at inclusion, with surgeon and patient being kept blind regarding the result. The patients underwent endoscopic CTR. QuickDASH and satisfaction score were recorded preoperatively and 4 months after surgery. 94 patients, 47 of whom had NCS-verified CTS, completed the study.

RESULTS

A significant improvement in QuickDASH score (18 and 20 points respectively, p < 0.01) was found for both groups. Satisfaction score was significantly higher in the group with NCS-verified CTS. However, the overall satisfaction rates were 87% in the normal NCS group and 95% in the group with abnormal NCS.

CONCLUSIONS

Clinical outcome after CTR in patients with normal NCS was favourable and similar to that obtained in patients with NCS-verified CTS. Nonetheless, patients with normal result in NCS gave a lower satisfaction score.

Effects of diabetes mellitus on the rate of carpal tunnel release in patients with carpal tunnel syndrome

The objective of this study was to evaluate the effects of diabetes mellitus (DM) on the rate of carpal tunnel release (CTR) using a large nationwide cohort in Korea and to identify risk factors, including comorbidities and socioeconomic status (SES), associated with CTR. Patients with a primary or secondary diagnosis of carpal tunnel syndrome (CTS; ICD-10 code: G560) were selected and divided into two groups according to the presence of DM. A Cox proportional hazard model was used to assess the rate of CTR between the two groups. To evaluate the influence of demographic factors, comorbidities, and SES on CTR, multivariate Cox proportional hazard regression models were used to adjust for confounding variables. In total, 12,419 patients with CTS were included in the study: 2487 in DM cohort and 9932 in non-DM cohort. DM duration was negatively related with the rate of CTR (HR = 0.89, 95% CI 0.87–0.91) in CTS patients with DM. The rate of CTR was decreased in patients with DM compared to those without DM in the unadjusted model; however, after adjusting for comorbidities, DM had no significant effect on the rate of CTR. Female sex (HR = 1.50, 95% CI 1.36–1.67) correlated with the rate of CTR, and an inverse relationship between the number of comorbidities and CTR was found (p < 0.001) irrespective of DM. Diabetic polyneuropathy (DPN) was not associated with CTR, and we did not find any factors correlating with CTR in DPN patients. We found that CTS patients with more comorbidities or combined with a longer duration of DM were undertreated in real-word practice. Actual outcomes of CTR in CTS patents with various comorbidities should be investigated in future studies for optimal management of CTS.

Vibrotactile sense 5 years after carpal tunnel release in people with diabetes: A prospective study with matched controls

AIM

To compare vibrotactile sense, 5 years after carpal tunnel release in people with and without diabetes.

METHODS

Out of 35 people with diabetes and carpal tunnel syndrome, age- and gender-matched with 31 people without diabetes but with idiopathic carpal tunnel syndrome, 27 and 30 people, respectively, participated in this prolonged follow-up. Vibration perception threshold of the index and little finger (median and ulnar nerve, respectively), 5 years after surgery, was measured at seven different frequencies (8, 16, 32, 64, 125, 250 and 500 Hz).

RESULTS

Significant improvement of vibration perception threshold from 1 to 5 years after carpal tunnel release was found at 64 Hz for people with diabetes, while improvement for people without diabetes was demonstrated at several frequencies (64-250 Hz). However, both groups demonstrated a significant decrease in vibration perception threshold for the low frequencies (8-16 Hz). At 5 years, people with diabetes had significantly impaired vibration perception threshold at the index finger for high frequencies (125-500 Hz), and for nearly all frequencies (16 Hz, 64-500 Hz) at the little finger, compared to people without diabetes.

CONCLUSION

After carpal tunnel release, significant mid-term improvement of vibrotactile sense appears limited for people with diabetes, compared to a continuous improvement for people without diabetes. In addition, a decline in low-frequency vibrotactile sense occurs for the median as well as the ulnar nerve innervated fingers. Clinical Trial Registration NCT01201109.

Subjective Outcomes of Carpal Tunnel Release in Patients with Diabetes and Patients without Diabetes

Introduction  This study aims to compare the subjective outcomes of carpal tunnel surgery in the patients with diabetes and patients without diabetes, and it tries to determine the difference between insulin-dependent and noninsulin-dependent patients. Materials and Methods  This retrospective cohort study compares subjective outcomes of 35 patients with type 2 diabetes and 35 patients without diabetes who had a unilateral carpal tunnel release. None of the patients with diabetes had neuropathy. All the patients had surgery by a single surgeon with miniopen incision under local anesthesia. The patients were evaluated before surgery and 6 months after surgery using two Brigham and Women's Carpal Tunnel Questionnaires Results  Carpal tunnel release was improved based on symptom severity scale (SSS) and functional status scale scores in patients with diabetes and nondiabetic patients. However, the mean SSS scores were higher in patients without diabetes 6 months after the surgery. Comparison between the mean SSS scores of the patients with diabetes showed higher scores in noninsulin-dependent patients. In patients with diabetes, SSS scores were positively correlated with carpal tunnel syndrome and diabetes durations. Conclusion  The outcomes of carpal tunnel release were improved in both patients with diabetes and patients without diabetes suffering from median nerve compression at the wrist. However, the duration of diabetes and its treatment can be related to the severity of the disease symptoms after the carpal tunnel releasing surgeries. In some diabetic patients, the severity of the symptoms was persistent. Level of Evidence  This is a prognostic level IV study.

Occurrence of cold sensitivity in carpal tunnel syndrome and its effects on surgical outcome following open carpal tunnel release

Cold sensitivity is common following nerve injuries in the upper extremity, but is less well studied in carpal tunnel syndrome (CTS). We investigated cold sensitivity in CTS and its effects on surgical outcome. A search of the Swedish National Registry for Hand Surgery (HAKIR) for open carpal tunnel releases (OCTR) from 2010-2016 identified 10,746 cases. Symptom severity questionnaires (HQ-8; HAKIR questionnaire 8, eight Likert-scale items scored 0-100, one item on cold sensitivity) and QuickDASH scores before and after surgery were collected. Patient mean age was 56 ± SD 16 years, and 7,150/10,746 (67%) were women. Patients with severe cold sensitivity (defined as cold intolerance symptom severity score > 70; n = 951), scored significantly higher on QuickDASH at all time points compared to those with mild cold sensitivity (cold intolerance symptom severity scores ≤ 30, n = 1,532); preoperatively 64 [50-75] vs. 40 [25-55], at three months 32 [14-52] vs. 18 [9-32] and at 12 months 25 [7-50] vs. 9 [2-23]; all p < 0.0001. Severe cold sensitivity predicted higher postoperative QuickDASH scores at three [12.9 points (95% CI 10.2-15.6; p < 0.0001)] and at 12 months [14.8 points (11.3-18.4; p < 0.0001)] compared to mild cold sensitivity, and adjustment for a concomitant condition in the hand/arm, including ulnar nerve compression, did not influence the results. Cold sensitivity improves after OCTR. A higher preoperative degree of cold sensitivity is associated with more preoperative and postoperative disability and symptoms than a lower degree of cold sensitivity, but with the same improvement in QuickDASH score.

Carpal Tunnel Syndrome Surgery: What You Should Know

Carpal tunnel release (CTR) surgery continues to evolve. Carpal tunnel syndrome remains a primarily clinical diagnosis, although ultrasound has supplemented electrodiagnostic testing as a confirmatory tool. Magnetic resonance imaging of the carpal tunnel has also showed some promise as an alternative method for the examination of the median nerve. Open CTR surgery remains the traditional, and most popular, method of CTR. Wide-Awake, with Local Anesthesia only, and No Tourniquet CTR has emerged as a means to decrease cost and improve pain control and convenience for patients. Endoscopic CTR is increasing in popularity due to its more rapid recovery. The safety profile of endoscopic CTR has improved, and recent studies show similar rates of major complications between open and endoscopic techniques. Nonsurgeon operated ultrasound-guided techniques for release of the transverse carpal ligament have emerged. While promising in early studies, the current evidence in their favor is limited in terms of patient numbers and direct comparison with other techniques. The outcomes of CTR continue to be excellent. Recent research has demonstrated that nerve conduction continues to recover postoperatively over a longer period of time than previously believed. Patient psychological factors play a significant role in outcomes after surgery but do not appear to limit the improvement provided by intervention.

[Carpal tunnel syndrome: Rare causes and associated forms behind a common and stereotyped affection]

Carpal tunnel syndrome (CTS) is too common a condition not to daily interact with the practitioner, if only because of its entanglement to other pathologies, causal or chance association. The typical symptomatology, with hand paresthesia and morning pain upon waking, is related to a median nerve injury in the confined space of the carpal tunnel, more often by local inflammation and tenosynovitis of the finger flexors (repetitive activity of the hands). SCC may be secondary to situations (pregnancy) or conditions (edema, hypothyroidism…), which exaggerate the ordinary pathophysiology or cause deposits in the channel (amyloidosis, mucopolysaccharidoses, etc.). Otherwise, SCC is favored by all neuropathies that cause nerve fragility (especially diabetes). It is sometimes the first sign of these various affections of which it can allow early diagnosis. Electroneuromyographic examination (ENMG) is a key examination to confirm the diagnosis (slowing of sensitive and motor conduction of the median nerve through the carpal tunnel, due to local demyelination), to look for a predisposing neuropathy and for signs of seriousness (amplitude reduction of electrophysiological signals) that indicate axonal loss. In SCC forms with only slowed conduction without sign of seriousness, a splint or infiltration treatment may be attempted. If this medical treatment does not bring healing, or if there are signs of seriousness or unbearable pains, a decompression surgery is indicated. Whether it is performed traditionally or endoscopically, it provides fast relief, even immediate.

Open carpal tunnel release and diabetes: a retrospective study using PROMs and national quality registries

OBJECTIVES

To study patient-reported outcome after open carpal tunnel release (OCTR) for carpal tunnel syndrome (CTS) in patients with or without diabetes using national healthcare quality registries.

DESIGN

Retrospective cohort study.

SETTING

Data from the Swedish National Quality Registry for Hand Surgery (HAKIR; www.hakir.se) were linked to data from the Swedish National Diabetes Register (NDR; www.ndr.nu).

PARTICIPANTS

We identified 9049 patients (10 770 hands) operated for CTS during the inclusion period (2010-2016).

PRIMARY OUTCOME MEASURES

Patient-reported outcome measures were analysed before surgery and at 3 and 12 months postoperatively using the QuickDASH as well as the HAKIR questionnaire with eight questions on hand symptoms and disability.

RESULTS

Patients with diabetes (n=1508; 14%) scored higher in the QuickDASH both preoperatively and postoperatively than patients without diabetes, but the total score change between preoperative and postoperative QuickDASH was equal between patients with and without diabetes. The results did not differ between patients with type 1 or type 2 diabetes. Patients with diabetic retinopathy scored higher in QuickDASH at 3 months postoperatively than patients with diabetes without retinopathy. In the regression analysis, diabetes was associated with more residual symptoms at 3 and 12 months postoperatively.

CONCLUSIONS

Patients with diabetes experience more symptoms both before and after OCTR, but can expect the same relative improvement from surgery as patients without diabetes . Patients with retinopathy, as a proxy for neuropathy, may need longer time for symptoms to resolve after OCTR. Smoking, older age, higher HbA1c levels and receiving a diabetes diagnosis after surgery were associated with more residual symptoms following OCTR.

Diagnosing and managing diabetic somatic and autonomic neuropathy

The diagnosis and management of diabetic neuropathy can be a major challenge. Late diagnosis contributes to significant morbidity in the form of painful diabetic neuropathy, foot ulceration, amputation, and increased mortality. Both hyperglycaemia and cardiovascular risk factors are implicated in the development of somatic and autonomic neuropathy and an improvement in these risk factors can reduce their rate of development and progression. There are currently no US Food and Drug Administration (FDA)-approved disease-modifying treatments for either somatic or autonomic neuropathy, as a consequence of multiple failed phase III clinical trials. While this may be partly attributed to premature translation, there are major shortcomings in trial design and outcome measures. There are a limited number of partially effective FDA-approved treatments for the symptomatic relief of painful diabetic neuropathy and autonomic neuropathy.

Electrodiagnosis in the Patient with Metabolic Syndrome: Adding Value to Patient Care

Patients with metabolic syndrome are at increased risk of peripheral neuropathy; entrapment neuropathies, such as carpal tunnel syndrome; and spine disease that can lead to radiculopathy or spinal stenosis. Electrodiagnostic studies are a valuable part of patient care in this population. They can confirm suspected diagnoses, uncover additional conditions, and lead to the diagnosis of other causes of neuropathy that require treatment. By assessing the severity of neuropathy, patients at high risk for falls, functional decline, and foot ulcers are identified to guide prevention, treatment, and patient education.