Current concepts in carpal tunnel syndrome: a review of the literature

Exploring the Non-Invasive Approaches to Carpal Tunnel Syndrome in Routine Clinical Practice: A Focus on the Role of Acetylcholinesterase Inhibitors

The prevalence of N. medianus compression neuropathies remains high in clinical practice. The objective was to evaluate modalities of conservative treatments for carpal tunnel syndrome (CTS) focusing on the role of acetylcholinesterase inhibitors. This observational study involved 51 adult outpatients diagnosed with CTS. Patients were observed during routine clinical protocols and we compared two groups of 25 and 26 individuals, with the first group receiving basic therapy for CTS and 20 mg of ipidacrine (Neiromidin®) two or three times a day per os, while the second group received only basic therapy. The condition of all patients was assessed twice, with at least a one-month interval. The parameters evaluated included the Boston Carpal Tunnel Questionnaire (BCTQ); the Disabilities of the Arm, Shoulder, and Hand scale (DASH); and pain intensity on the Numeric Rating Scale (NRS). The mean reduction in DASH score was 12.3 (SD 7.7) in Group 1 and 7.1 (SD 6.3) in Group 2 (p < 0.01). Also, other scores showed statistically significant differences between the two groups: -2.3 vs. -1.0 for NRS, -0.89 vs. -0.44 for SSS, and -0.68 vs. -0.31 for FSS, respectively (p < 0.01). Moreover, these findings correlated positively with the global improvement (CGI-I) between the groups. The addition of ipidacrine to basic therapy led to improved recovery in patients with CTSs of varying severity.

The Influence of Corticosteroid Injections on Postoperative Outcomes of Carpal Tunnel Release: A Systematic Review

Background  Carpal tunnel syndrome can be treated with corticosteroid injections (CIs) and surgery. In this systematic review, the influence of previous CI on different postoperative outcomes after carpal tunnel release is evaluated. Methods  A systematic literature search using several databases was performed to include studies that examined patients diagnosed with carpal tunnel syndrome who received preoperative or intraoperative CIs. Results  Of 2,459 articles, 9 were eligible for inclusion. Four papers reported outcomes of preoperative and four outcomes of intraoperative CIs. One study evaluated patients who received both intraoperative and preoperative corticosteroids. Conclusion  Intraoperative CIs are associated with reduced postoperative pain after carpal tunnel release and support earlier recovery of the hand function that can be objectified in a faster median nerve conduction speed recovery and lower Boston Carpal Tunnel Questionnaire (BCTQ) scores. Using preoperative CIs did not lead to enhanced recovery after carpal tunnel release, and both preoperative and intraoperative CIs might be predisposing factors for infections.

Sickness absence and disability pension after carpal tunnel syndrome diagnosis: A register-based study of patients and matched references in Sweden

Aims: The aim of this study was to examine sickness absence and disability pension (SA/DP) during working lifespan among individuals diagnosed with carpal tunnel syndrome (CTS) and their matched references, accounting for sociodemographic factors. Methods: We used a register cohort of 78,040 individuals aged 19-60 years when diagnosed with CTS in secondary health care (hospitals and outpatient specialist health care) and their 390,199 matched references from the general population in 2001-2010. Sociodemographic factors and SA/DP net days during a three-year follow-up were included. Negative binomial regression was used. Results: For those not on DP at inclusion, the average number of SA/DP days per person-year was 58 days (95% confidence interval (CI) 56-60 days) among individuals with CTS and 20 days (95% CI 19-21 days) among the matched references. Among both groups, these numbers increased with age and were higher among women than among men. The rate ratio (RR) of SA/DP days was threefold higher among people with CTS than among the matched references (adjusted RR=3.00, 95% CI 2.91-3.10) Moreover, compared to the matched references, the RR for SA/DP was higher among men with CTS (RR=3.86, 95% CI 3.61-4.13) than among women with CTS (RR=2.69, 95% CI 2.59-2.78). The association between CTS and the number of SA/DP days was smaller among older age groups. Sociodemographic factors were similarly associated with SA/DP among people with and without CTS. Conclusions: Numbers of SA/DP days were higher among people with CTS than their matched references in all age groups, particularly among individuals in their early work careers, highlighting public-health relevance of the findings.

The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius

Background

Acute carpal tunnel syndrome (ACTS) is a known complication of distal radius fractures. This study aimed to document the demographics, range of presenting symptoms and risk factors of patients who develop ACTS following a fracture of the distal radius.

Methods

A retrospective review of 1189 patients with an acute distal radius fracture treated in the study centre over a one-year period were identified. Demographic and clinical variables were collected and compared between controls (did not develop ACTS) and those patients who did develop ACTS to identify factors associated with developing ACS.

Results

There were 51 (4.3%) distal radius fractures complicated by ACTS. The mean age of patients who developed ACTS was 56 years (range, 16–89) and 73% were female. The median time of onset post-injury was one week (range, 1–12). There was no association between patient background and comorbidities with the development of ACTS. AO-OTA Type C fractures had significantly increased rates of developing ACTS.

Conclusion

Four percent of distal radius fractures were complicated by ACTS. There was no association between patient background and comorbidities with the development of ACTS. AO-OTA type C complete articular fractures had a significantly higher rate of ACTS. A suggested treatment algorithm for patients presenting with ACTS has been presented.

Level of evidence:

III.

What Types of Treatment Are Provided for Patients With Carpal Tunnel Syndrome? A Retrospective Analysis of Commercial Insurance

BACKGROUND

Treatment of carpal tunnel syndrome (CTS) in commercially insured patients across the spectrum of provider types rarely has been described.

OBJECTIVE

To describe patterns of types of treatment for patients with CTS using a large commercial insurance database.

DESIGN

Retrospective cohort descriptive study.

SETTING

Administrative health data from the Clinformatics Data Mart (OptumInsight, Eden Prairie, MN).

PATIENTS

Adults with a primary diagnosis of CTS seen from between January 2010 to December 2012 who had a total of 48 months of continuous data (12 months before diagnosis and 36 months after diagnosis) (n = 24,931).

OUTCOMES

Frequency of types of treatment (heat, manual therapy, positioning, steroids, stretching, surgery) by number of treatments, number of visits, provider type, and characteristics.

RESULTS

Fifty-four percent of patients received no reported treatment, and 50.4% had no additional visits. Surgery (42.5%) and positioning (39.8%) were the most frequent single treatments. Patients who were seen by orthopedist for their first visit more frequently received some treatment (75.1%) and at least 1 additional visit (74.1%) compared with those seen by general practitioners (59.5%, 57.5%, respectively) or other providers (65.4%, 68.4, respectively). Orthopedists more frequently prescribed positioning devices (26.8%) and surgery (36.8%) than general practitioners (18.8%, 14.1%, respectively) or other providers (15.7%, 19.7%, respectively). Older adults more frequently had CTS surgery, as did people who lived in the Midwest. Overall, only 24% of patients with CTS had surgery.

CONCLUSIONS

For more than one-half of patients with CTS no treatment was provided after an initial visit. Surgery rates were much lower than what has previously been reported in the literature. Generally, patients with CTS receive treatments that are supported by current treatment guidelines.

LEVEL OF EVIDENCE

NA.

New candidates for treatment and management of carpal tunnel syndrome based on the Persian Canon of Medicine

Carpal tunnel syndrome (CTS) is defined as a compressing median mononeuropathy. CTS is one of the major costly debilitating diseases of the hand. Although CTS is a relatively recent concept in current medicine, some evidences show that medieval physicians in Persian medicine (PM) such as Avicenna were familiar with it. The PM textbook written by Avicenna, the Canon of Medicine, defines the anatomy of carpal tunnel and median nerve, as well as mononeuropathy; it also offers suggestions for the prevention and treatment of carpal tunnel syndrome (called as Vaja al-asab and Khadar) in the chapter of nerve diseases. The book describes not only symptoms including pain, paresthesia, hypoesthesia, tingling, and numbness, but also its etiology such as nerve compression (entrapment neuropathy); nonphysical reasons such as disturbed balance among the four body humors; alteration in the nerve's temperament (Mizaj) that prevents the transmission of nerve impulses; and the others such as nutrition, mental condition, sleep, weather condition, body movements, and proper disposal of body waste. Furthermore, the book suggests a lifestyle modification method based on six factors and 10 prescriptions composed with 85 natural products that are not actively used for CTS treatment in modern times. The medicinal suggestions for CTS in the Canon of Medicine will be good candidates for discovering new treatments besides providing historical significance to the various insights considered 1000 years ago.

A Clinical Study of the Modified Thread Carpal Tunnel Release

BACKGROUND

Previous studies have indicated that the thread carpal tunnel release (TCTR) is a safe and effective technique. Through a study on 11 cadaveric wrists, the TCTR procedure was modified and the needle control accuracy was improved to 0.15 to 0.2 mm, which is precise enough to preserve superficial palmar aponeurosis (SupPA), Berrettini branch, and common digital nerves. The aim of the present study was to verify the modified TCTR clinically.

METHODS

The modified TCTR was performed on 159 hands of 116 patients. The Boston Carpal Tunnel Syndrome Questionnaire was used for assessing the outcomes. Statistical analyses were used to compare the outcomes with the available data from the literature for the open and endoscopic techniques.

RESULTS

TCTR led to significant improvement in the short-term results, and the outcomes were better in long-term results compared with the open or endoscopic release. The SupPA, Berrettini branch, and common digital nerves were protected. There was no neurovascular complication for any case. Significant relief of symptoms was observed 3 to 5 hours post procedure. Most patients used their hands on the day of the procedure for simple daily activity. Patients reported their sleep quality was improved on the surgical day. Most patients with office jobs were able to return to work on postoperative day 1, and those with repetitive jobs returned to work in about 2 weeks. The statistical evidence proves that the modified TCTR procedure results in improved clinical outcomes as compared with open carpal tunnel release (CTR) and endoscopic CTR.

CONCLUSIONS

The TCTR procedure has been shown to be a safe and effective technique for CTR. The modified TCTR procedure minimizes postoperative complications, such as pillar pain, scar tenderness, or functional weakness, by avoiding unnecessary injuries to the surrounding structures around the transverse carpal ligament during the procedure.

A Cadaveric Study for the Improvement of Thread Carpal Tunnel Release

PURPOSE

The thread carpal tunnel release (TCTR) technique has been improved and offers more precise control in dissecting thread placement. The purpose of this cadaveric study was to test the procedure operationally and verify the modified TCTR anatomically.

METHODS

Eleven unembalmed cadaver wrists underwent the transverse carpal ligament (TCL) release by using the modified TCTR technique. An experienced observer dissected each specimen and assessed for completeness of release under direct visual assessment. Injury to the superficial palmar aponeurosis (SupPA), the Berrettini and common digital nerve branches were also recorded as a secondary outcome.

RESULTS

Eleven out of 11 wrists (100%) underwent the modified TCTR with complete release of the TCL. All 11 wrists were released without damage to any vital neurovascular structure including the Berrettini branch and the common digital nerves. The SupPA remained intact in all 5 wrists performed with the preservation steps.

CONCLUSIONS

The modified TCTR technique demonstrated complete division of the TCL while protecting the SupPA as well as the Berrettini and common digital nerve branches.

CLINICAL RELEVANCE

The modified TCTR has the potential to offer a clinically safe and effective minimally invasive procedure for complete carpal tunnel release.

Similar effectiveness of the open versus endoscopic technique for carpal tunnel syndrome: a prospective randomized trial

This prospective randomized study aims at evaluating the electrophysiological results of endoscopic and open carpal ligament release in patients with carpal tunnel syndrome. Included in the study were 41 patients diagnosed with carpal tunnel syndrome (21 hands in the endoscopic group and 20 hands in the open group). The Boston questionnaire was administered preoperatively and postoperatively to the patients, and their functional capacities and symptom severities were recorded. Physical examination was carried out preoperatively and in the postoperative sixth month. Demographic data and preoperative Boston symptomatic and functional scores were similar between both groups. A significant improvement was obtained in the Boston symptomatic and functional scores of both groups, but no significant difference was found between the groups in terms of improvement in the symptomatic and the functional scores. A significant shortening in median nerve motor distal latency and an increase in the velocity of sensory conductions were determined in both groups in the postoperative electromyography, but no difference was found between them in terms of improvement in the electromyography values. It was shown both clinically and electrophysiologically that endoscopic carpal tunnel surgery was as effective as open surgery as a treatment method for carpal tunnel syndrome.

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Background

NHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.

Objectives

We aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.

Methods

We used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.

Results

There was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.

Conclusions

Policy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A non-scalpel technique for minimally invasive surgery: percutaneously looped thread transection of the transverse carpal ligament

PURPOSE

This study aims to develop an alternate technique for improving the surgical procedure of carpal tunnel release.

METHOD

The transverse carpal ligament is transected by utilizing a piece of thread looped percutaneously under the visualization of ultrasound. The procedure, the thread carpal tunnel release (TCTR), was performed on 34 hands of 20 patients. Self-administrated Levine-Katz questionnaire was used for assessing the symptom severity and functional status of the outcomes.

RESULTS

TCTR was performed in each case with no unintended consequences. The average duration for a procedure was 7 min, excluding time of preparation. Significant improvements in subjective sensibility were reported within 24 h, and sleep quality improved for all cases. There were no postoperative complications. The scores of questionnaire 3 months postoperatively were comparable to the literature controls.

CONCLUSION

TCTR is a safe and effective minimally invasive surgery performed under local anesthesia in a clinic-based procedure room and results in only one-needle entrance point at the wrist and one-needle exit point in the palm. The feature of the procedure includes the potentials of reduced risk of iatrogenic injury, reduced surgical cost, and reduced patient recovery time. The study has shown encouraging promise for optimizing the technique of carpal tunnel release, and more clinical trials are necessary to confirm the findings.

Symptom severity and conservative treatment for carpal tunnel syndrome in association with eventual carpal tunnel release

PURPOSE

To study the relationship between the severity of carpal tunnel syndrome (CTS) symptoms and surgery for CTS and the relationship between conservative treatments and surgery for CTS.

METHODS

A secondary analysis of baseline to 6-month data from a randomized controlled trial, which examined the effectiveness of orthosis/stretch combinations on the symptoms of CTS, was conducted for a total of 96 participants with CTS. Participants completed the Carpal Tunnel Questionnaire and posttreatment surveys. Statistical analyses included exploration of correlates of progression to surgery for CTS and logistical regression to examine the association between conservative treatments and CTS symptoms and progression to surgery for CTS.

RESULTS

Twenty-one participants received surgery for their CTS, and 31 participants received 1 or more conservative treatments. Severity of baseline CTS symptoms and additional treatments were indicators of progression to surgery. The randomized controlled trial intervention was inversely associated with progression to surgery.

CONCLUSIONS

CTS that does not respond to an initial course of conservative treatment may not improve with additional treatments. More than half of the participants who received additional conservative treatment still progressed to surgery. Current intervention guidelines for CTS provide limited guidance as to the best methods to efficiently treat CTS.

CLINICAL RELEVANCE

CTS is a costly and high-burden disorder, resulting in reduced quality of life. Research should examine when and for whom conservative care is an effective choice and the association between conservative care and the eventual need for CTS surgery.

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.

Percutaneous ultrasound-guided MANOS carpal tunnel release technique

Ultrasound (US) is used with a minimally invasive cutting device to perform carpal tunnel release with a 3 mm wrist incision. US localizes tendons, arteries, and median nerve for safe introduction of the device into the wrist. The device is inserted in a blunt configuration under the flexor retinaculum, and a cutting wire is deployed that advances a 0.9-mm needle in the palm. The surgeon releases the flexor retinaculum from the inside out through the two skin punctures. Flexor retinaculum release is confirmed with US.

Relationship between intraneural vascular flow measured with sonography and carpal tunnel syndrome diagnosis based on electrodiagnostic testing

OBJECTIVES

The purpose of this study was to document and analyze intraneural vascular flow within the median nerve using power and spectral Doppler sonography and to determine the relationship of this vascular flow with diagnosis of carpal tunnel syndrome based on electrodiagnostic testing.

METHODS

Power and spectral Doppler sonograms in the median nerve were prospectively collected in 47 symptomatic and 44 asymptomatic subjects. Doppler studies were conducted with a 12-MHz linear transducer. Strict inclusion criteria were established for postexamination assessment of waveforms; routine quality assurance was completed; electrodiagnostic tests were conducted on the same day as sonographic measurements; and the skin temperature was controlled. Included waveforms were categorized by location and averaged by individual for comparative analysis to electrodiagnostic testing.

RESULTS

A total of 416 waveforms were collected, and 245 were retained for statistical analysis based on strict inclusion criteria. The mean spectral peak velocity among all waveforms was 4.42 (SD, 2.15) cm/s. At the level of the pisiform, the most consistent data point, mean peak systole, was 3.75 cm/s in symptomatic patients versus 4.26 cm/s in asymptomatic controls. Statistical trending showed an initial increase in the mean spectral peak velocity in symptomatic but diagnostically negative cases, with decreasing velocity as diagnostic categories progressed from mild to severe.

CONCLUSIONS

An inverse relationship may exist between intraneural vascular flow in the median nerve and an increasing severity of carpal tunnel syndrome based on nerve conduction results. Randomized controlled trials are needed to determine whether spectral Doppler sonography can provide an additive benefit for diagnosing the severity of carpal tunnel syndrome.

Carpal tunnel syndrome and metabolic syndrome co-occurrence

We aimed to evaluate the relation between the severity of carpal tunnel syndrome and metabolic syndrome. One hundred and fifty patients who had a clinical and electrophysiologically confirmed diagnosis of carpal tunnel syndrome (CTS), were included in this study. The patients were divided into two groups (with or without metabolic syndrome) according to the criteria of National Cholesterol Education Program. Eighty one (73.5 %) of the patients with CTS had metabolic syndrome. The patients with metabolic syndrome the severity of CTS was found 22.2 % had mild CTS, 56.8 % had moderate CTS, and 21 % had severe CTS. The patients without metabolic syndrome the severity of CTS was found 44.9 % had mild CTS, 40.6 % had moderate CTS, and 14.5 % had severe CTS. The severity of CTS between both groups was found to be statistically significant (p = 0.0009). While a correlation was found between the severity of CTS and high level of LDL with the presence of metabolic syndrome (correlation coefficient 0.209). In conclusion metabolic syndrome that appears to be a risk factor for CTS. At the same time, the presence of metabolic syndrome increases the severity of the disease.