Electrophysiological responsiveness and quality of life (QuickDASH, CTSI) evaluation of surgically treated carpal tunnel syndrome

Association between three-dimensional motion analysis of the thumb and clinical parameters in patients with carpal tunnel syndrome

We analysed the relationship between motor dysfunction of the thumb and the clinical parameters of carpal tunnel syndrome using three-dimensional motion analysis. This single-centred, prospective study included 65 hands in 51 patients with idiopathic carpal tunnel syndrome and 30 healthy hands. Three-dimensional thumb kinematics were acquired using a motion capture system with a retroreflective surface-based marker method. The trajectory area of thumb tip, adduction and abduction of the trapeziometacarpal joints and metacarpophalangeal joints were correlated with the clinical parameters. There was no significant correlation between the results of motion analysis values and patient-reported outcomes measures. Thumb movement disorder associated with carpal tunnel syndrome affected specific activities of daily living based on the pinching movements, such as 'writing' and 'buttoning clothes' among the patient-reported outcome measure items.Level of evidence: III.

Rasch analysis of the carpal tunnel syndrome instrument

BACKGROUND

The carpal tunnel syndrome instrument (CTSI) is the most widely used patient-reported outcome measure (PROM) in carpal tunnel syndrome (CTS). However, CTSI is an ordinal-type questionnaire and might have caused misinterpretations of the PROM between surgical outcomes of CTS (Camitz and extra/open carpal tunnel release).

PURPOSE

This study aims to convert the CTSI to an interval scale using Rasch analysis (RA) and evaluate the outcome differences between the original and transformed scales.

STUDY DESIGN

Prospective control study.

METHODS

Four hundred twenty-four patients with 567 CTSs had been interviewed for CTSI perioperatively and treated with either endoscopic/open carpal tunnel release or Camitz tendon transfer. Each CTSI was analyzed for dimensionality, fit statistics, and a transformation of the ordinal-to-interval scale by RA. We compared the two groups perioperative scores of three CTSI versions (original 11-item, modified 8-item, and transformed 8-item).

RESULTS

Based on the RA, the original CTSI was not unidimensional. We identified two dimensions. After removing misfit items, the perioperative course of each score by three versions of each dimension was compared (Repeated 2-factor analysis of variance). The transformed interval scales of CTSI provided different assessments of score changes from the ordinal scale of CTSI analyses.

CONCLUSIONS

Original CTSI consisted of ordinal scale items that yielded different conclusions than scores converted to interval scale by Rasch analysis. CTSI should convert into an interval scale after reclassifying dimensionality by Latent Factor Analysis and removing misfit items.

Re-evaluation of the Indications for the Camitz Procedure in Severe Carpal Tunnel Syndrome

PURPOSE

The modified Camitz procedure has been used to improve thumb opposition in patients with severe carpal tunnel syndrome (CTS), although its indications remain controversial. This study compared the functional recovery of thumb opposition following carpal tunnel release with and without a concomitant Camitz procedure. We used the Carpal Tunnel Syndrome Instrument questionnaire (CTSI) and the compound muscle action potential of the abductor pollicis brevis (APB-CMAP) to assess the recovery.

METHODS

Five hundred sixty-seven hands underwent surgical treatment for CTS following electrophysiologic studies and the CTSI. The procedures included carpal tunnel release (either endoscopic carpal tunnel release [ECTR] or open carpal tunnel release [OCTR]) and OCTR with a Camitz procedure. One hundred thirty-six patients with absent preoperative APB-CMAP constituted the material of our study. The CTSI and APB-CMAP recoveries between the "ECTR/OCTR group" and the "Camitz group" were compared before surgery and at three, six, and 12 months after surgery.

RESULTS

There were no statistically significant differences in recovery between the "ECTR/OCTR group" and the "Camitz group" according to the three scales of CTSI (symptom severity scale, functional state scale, and FS-2 item, buttoning clothes: an alternative test of thumb opposition) and the APB-CMAP.

CONCLUSION

Carpal tunnel release procedures resulted in the useful recovery of thumb opposition without the need for Camitz, even if APB-CMAP did not fully recover. The action of the other synergistic muscles acting on the thumb and the sensory recovery may have contributed to the recovery of thumb opposition. The Camitz procedure also may be only rarely indicated for hands affected by severe CTS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Ultrasound of the Median Nerve in the Surgical Treatment of Severe Carpal Tunnel Syndrome

BACKGROUND

High-resolution ultrasound (HRU) has demonstrated utility in the diagnosis and treatment of carpal tunnel syndrome (CTS) by measuring the cross-sectional area (CSA) of the median nerve. We investigated whether HRU could be helpful in evaluating outcomes of carpal tunnel release in patients with severe CTS.

METHODS

Patients greater than 18 years of age with severe CTS on electrodiagnostic (EDX) studies and scheduled to have carpal tunnel release were enrolled. At baseline visit within 6 weeks preoperatively, HRU was used to measure median nerve CSA at the carpal tunnel inlet and forearm, and the wrist/forearm ratio (WFR) was calculated. Patients also completed the Boston Carpal Tunnel Questionnaire (BCTQ). Ultrasound and BCTQ were repeated at 6 weeks and 6 months postoperatively.

RESULTS

Twelve patients completed the study (average age, 69 years; range, 52-80 years). The WFR improved significantly at 6 weeks and reached normal levels at 6 months. The CSA at the wrist also improved at 6 months, although this did not reach statistical significance (P = .059). Boston Carpal Tunnel Questionnaire symptoms and function scores improved significantly at 6 weeks and 6 months.

CONCLUSIONS

High-resolution ultrasound provides an objective assessment of surgical outcomes in cases of severe CTS, demonstrating normalization of WFR in our series of successful cases. Future study of poor outcomes may help determine whether improvement in WFR and CSA can provide reassurance and support for observation rather than reoperation. Ultrasound also provides anatomical evaluation and may be helpful in cases with medicolegal or psychosocial issues while potentially being less costly and better tolerated than EDX or magnetic resonance imaging.

Long-Term Outcome of Electrodiagnostic Values and Symptom Improvement After Carpal Tunnel Release: A Retrospective Cohort Study

PURPOSE

The aim of this study was to evaluate electrodiagnostic studies and clinical outcomes after carpal tunnel release surgery in moderate and severe cases of carpal tunnel syndrome (CTS).

METHODS

Seventy-two patients with moderate or severe CTS who underwent carpal tunnel release surgery (46 unilateral; 26 bilateral; total, 98 surgeries) between 2009 and 2014 were included in the study. The cases were divided into 2 groups according to electrodiagnostic results: those with moderate CTS and those with severe CTS. Michigan Hand Outcomes Questionnaire scores and electrodiagnostic data (sensory nerve action potentials and compound muscle action potentials) were recorded before surgery and in postoperative follow-up studies obtained at 3 months, 1 year, and 5 years.

RESULTS

There were 56 surgeries in the moderate CTS group and 42 surgeries in the severe CTS group. Sensory nerve action potentials and compound muscle action potentials were significantly lower in the severe CTS group when compared to the moderate CTS group at all follow-up times. There was a significant difference in Michigan Hand Outcomes Questionnaire scores between the groups before surgery, but no significant differences at the final follow-up. It was found that the values of all parameters (sensory nerve action potentials, compound muscle action potentials, and Michigan Hand Outcomes Questionnaire score) demonstrated significant improvements with time in both the severe and the moderate CTS groups.

CONCLUSIONS

Carpal tunnel release surgery improves symptoms, regardless of the preoperative severity. Postoperative electrodiagnostic study results of patients with moderate CTS improve to a greater degree than those of patients with severe CTS, but all remain abnormal.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IIb.

Evaluation of carpal tunnel release outcomes by the Japanese version of the carpal tunnel syndrome questionnaire compared to an electrophysiological severity grade

BACKGROUND

The outcome of carpal tunnel release (CTR) one year postoperatively was assessed by the Japanese version of Carpal tunnel syndrome questionnaire, CTSI-JSSH. Patients were further graded by the electrophysiological severity scale and the CTSI-JSSH scores were compared amongst the Stages before surgery and one-year postoperatively.

METHODS

This study included 247 hands and the mean age of the patients was 68 years (range:26-91). They completed the CTSI-JSSH consisting of the two subscales of the symptom scale (CTSI-JSSH-SS) and the functional scale (CTSI-JSSH-FS) both preoperatively and at the follow-up period of one year. The change of the scores of the CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH were examined. Electrophysiological examination was performed before CTR and graded according to the electrophysiological severity scale as Stage 1-5. The scores of the CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH were compared amongst Stage 1-5.

RESULTS

All CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH scores improved significantly one-year postoperatively. Also, the standardized response mean (SRM) and effect size (ES) showed large responsiveness, i.e. 1.36/1.43, 1.12/1.08 and 1.43/1.45 respectively. There was no significant difference in the score of the CTSI-JSSH-SS, CTSI-JSSH-FS and total CTSI-JSSH amongst any of the Stages preoperatively, while the scores in Stage 5 were significantly inferior to the ones in Stages 3 and 4 one-year postoperatively.

CONCLUSIONS

The clinical outcomes of CTR were favorable by assessment of the CTSI-JSSH. We suggest the postoperative inferior scores in Stage 5 may be due to the potential axonal damage which could explain the disappearance of distal motor latency and sensory nerve conduction velocity in Stage 5.

Relationship between clinical outcomes and nerve conduction studies before and after surgery in patients with carpal tunnel syndrome

Background

Nerve conduction study (NCS) is the only useful test for objective assessment of carpal tunnel syndrome (CTS). However, the relationship between pre- and postoperative NCS and clinical outcomes was unclear. This study aimed to determine whether pre- and postoperative (6 months) NCS could predict patient-oriented and motor outcomes (6 and 12 months postoperatively) in patients with CTS.

Method

Of the 85 patients with CTS, 107 hands were analyzed from March 2011 to March 2020. All patients underwent open carpal tunnel release and were examined using the disabilities of the arm, shoulder and hand (DASH) questionnaire and grip strength (GS) preoperatively and 6 and 12 months postoperatively. Moreover, NCS was examined preoperatively and 6 months postoperatively. Distal motor latency (DML) and sensory conduction velocity (SCV) were the parameters used for NCS. The correlation coefficient between NCS and DASH or GS was calculated. A receiver operating characteristic curve was utilized to determine the NCS threshold value to predict DASH and GS improvement.

Results

The average scores of GS preoperatively and 6 and 12 months postoperatively were 21.3, 22.3, and 22.8, respectively. On the other hand, the average scores of DASH preoperatively and 6 and 12 months postoperatively were 28.8, 18.3, and 12.2, respectively. The average NCS scores (DML and SCV) preoperatively/6 months postoperatively were 7.3/5.4 and 27.8/36.7, respectively. Preoperative NCS did not correlate with DASH and GS. Postoperative SCV correlated with the change in grip strength (6–12 months, r = 0.67; 0–12 months, r = 0.60) and DASH (0–12 months, r = 0.77). Moreover, postoperative DML correlated with the change in DASH (6–12 months, r = − 0.33; 0–12 months, r = − 0.59). The prediction for the improvement of GS/DASH achieved a sensitivity of 50.0%/66.7% and a specificity of 100%/100%, at an SCV cutoff score of 38.5/45.0 or above. The prediction for improvement of GS/DASH achieved a sensitivity of 83.3%/66.7% and a specificity of 100%/66.7% at a DML cutoff score of 4.4/4.4 or below.

Conclusion

NCS at 6 months postoperatively can be used to predict the improvement of clinical outcome after 6 months postoperatively in patients with CTS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04771-y.

Is Boston questionnaire an alternative to electromyography for evaluation of the surgical outcome for carpal tunnel syndrome?

Objectives

This study aims to identify the optimal follow-up method for evaluation of the surgical outcome for carpal tunnel syndrome (CTS).

Patients and methods

Between January 2006 and December 2010, 61 hands of a total of 46 patients (7 males, 39 females; mean age 56.0±10.4 years; range, 20 to 71 years) with a diagnosis of CTS were retrospectively analyzed. All operations were performed by a single surgeon with a mini-incision distal to the transverse carpal ligament. At a mean follow-up of seven years after surgery, electromyography (EMG) was repeated for all patients. The Boston Carpal Tunnel Questionnaire (BCTQ), Boston Symptom Severity Scale, Boston Functional Status Scale, palmar pinch strength, grip strength, and EMG of the patients were compared before and after surgery.

Results

The mean follow-up was 84±10 (range, 72 to 104) months. There were significant improvements in the Boston Symptom and Functional Scale scores postoperatively, as well as in the grip and pinch strength. After surgery, EMG findings improved in 83.6% of the patients. However, there was no significant correlation between pre- and postoperative Boston Symptom Severity Scale scores, functional status, pinch and grip strengths, and pre- and postoperative EMG results.

Conclusion

Our study results demonstrate that the symptom severity and functional status scores of the BCTQ are favorable, and this tool is reliable and easy-to-apply for the diagnosis and follow-up of CTS surgeries.

Upper extremity disability is associated with pain intensity and grip strength in women with bilateral idiopathic carpal tunnel syndrome

BACKGROUND

The upper extremity disability in patients with carpal tunnel syndrome (CTS) is related to dysfunction due to the median nerve damage. However, there is no report on which dysfunctions affect the upper extremity disability.

PURPOSE

This study aimed to investigate which clinical factors influence upper extremity disability in women with CTS.

METHODS

We analyzed 60 hands of women with bilateral idiopathic CTS. Upper extremity disability was assessed using Hand10, a validated and self-administered tool. Pain intensity was measured using the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-J). We performed nerve conduction studies, assessed physical and psychological parameters, and collected demographic data. Physical parameters comprised grip strength, pinch strength, tactile threshold, static 2-point discrimination sensation, and severity of numbness. Psychological parameters include depression, pain anxiety, and distress.

RESULTS

The bivariate analysis revealed that Hand10 was significantly correlated with age, symptom duration, SF-MPQ-J, grip strength, pain anxiety, and distress. Multiple regression analysis demonstrated that SF-MPQ-J and grip strength were related to Hand10 score.

CONCLUSIONS

Pain intensity and grip strength were dysfunctions affecting the upper extremity disability in women with bilateral idiopathic CTS. Rehabilitation approaches for CTS should be considered based on the adaptive activities of the neural networks.

Validity, Reliability and Responsiveness of the Korean Version of Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire in Patients with Carpal Tunnel Syndrome

BACKGROUND

The Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) is one of the most widely used questionnaires for assessing functional ability of the patients with upper extremity diseases. Carpal tunnel syndrome (CTS) is the most common neuropathic disease in the upper extremities. The aim of this study was to verify the validity, reliability, and responsiveness of Korean version of QuickDASH questionnaire (K-QuickDASH) in the patients with CTS.

METHODS

In total, 83 subjects who underwent open carpal tunnel release (CTR) operation were selected. They fulfilled Korean version of Disabilities of the Arm, Shoulder and Hand questionnaire (K-DASH) and K-QuickDASH at two different time points: before and six months after the surgery. Both criterion-related and construct validities were evaluated using Pearson's correlation coefficient and factor analysis. Internal consistency was estimated using Cronbach's alpha, and test-retest reliability was assessed to verify the reliability of K-QuickDASH using intraclass correlation coefficient (ICC). The standardized response mean and the effect size were analyzed to confirm the responsiveness of the K-QuickDASH in CTS patients.

RESULTS

Significant positive correlation was found between K-QuickDASH and K-DASH. All the questionnaire items were categorized into three factors. Acceptable internal consistency was confirmed in three categories of K-QuickDASH. A high test-retest reliability and responsiveness of K-QuickDASH were detected.

CONCLUSION

K-QuickDASH in Korean patients with CTS was confirmed to have high degree of validity and reliability, and responsiveness after CTR. Therefore, the K-QuickDASH would be a good evaluation tool for evaluating clinical symptoms and determination of treatment outcomes in the patients with CTS.

Favorable Responsiveness of the Hand10 Questionnaire to Assess Treatment Outcomes for Lateral Epicondylitis

BACKGROUND

The aim of our study was to compare the responsiveness of the Hand10 questionnaire and the Pain visual analogue scale (VAS) for the assessment of lateral epicondylitis.

METHODS

The standardized response mean and effect size were used as indicators of responsiveness, measured at baseline and after 6 months of treatment. Among the 54 patients enrolled, 28 were treated using a forearm band, compress and stretching, with the other 26 patients treated using compress and stretching.

RESULTS

The standardized response mean and the effect size were 1.18 and 1.38, respectively, of the Hand10 and 1.39 and 1.75, respectively, for the Pain VAS.

CONCLUSIONS

The responsiveness of both tests was considered to be large, based on Cohen's classification of effect size, supporting the use of the Hand10 questionnaire to assess treatment outcomes for lateral epicondylitis.

Patient-Reported Disability Measures Do Not Correlate with Electrodiagnostic Severity in Carpal Tunnel Syndrome

Background:

Electrophysiologic studies including electromyography and nerve conduction studies play a role in the evaluation of carpal tunnel syndrome (CTS), despite evidence that these studies do not correlate with CTS-specific symptom scores. There is a lack of evidence comparing electrophysiologic data with general measures of function.

Methods:

Fifty patients presenting for CTS treatment over an 8-month period were analyzed retrospectively. All patients completed surveys including the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and the Medical Outcomes Study 12-Item Short-Form Survey [(physical component summary 12, mental component summary (MCS-12)]. Electromyography and nerve conduction studies were performed on all patients and compared with outcome scores.

Results:

Analysis demonstrated no relationship between DASH or MCS-12 and electrodiagnostic severity. No significant correlations were noted between DASH or MCS-12 and median motor or sensory latency. There was a moderate–weak correlation (rho = 0.34) between more severe electrophysiologic grade and better function based on physical component summary 12.

Conclusions:

Electrodiagnostic severity grades do not correlate with patient-reported disability, including the DASH and MCS–12 surveys. There is a counterintuitive correlation between more-severe electrodiagnostic findings and decreased physical disability. These findings indicate that disability may not correlate with electrodiagnostic severity of median neuropathy in CTS.

Electrophysiological Assessment for Splinting in the Treatment of Carpal Tunnel Syndrome

An electrophysiological study is commonly used to decide a therapeutic strategy for carpal tunnel syndrome (CTS). In this study, the electrophysiological parameter measurement as a prognostic indicator for CTS after wrist splinting was assessed to identify appropriate candidates for wrist splinting for CTS. One hundred and six hands in 78 patients with CTS were treated by wrist splinting, and three electrophysiological parameters; median distal motor latency (DML) of the abductor pollicis brevis (APB) muscle, median distal sensory latency (DSL) of the index finger, and second lumbrical-interossei latency difference (2L-INT LD); were statistically analyzed to compare with clinical results by Kelly’s evaluation respectively. Clinical results were excellent in 15 hands, good in 51 hands, fair in 19 hands, and poor in 21 hands. The recordable rate in 2L-INT LD (99.1%) was higher than DML (96.2%) and DSL (79.2%). Patients with DML less than 6.5 ms, DSL less than 5.7 ms, or 2L-INT LD less than 2.5 ms had significantly excellent or good clinical results. The odds ratios of the DML, DSL, and the 2L-INT LD were 7.93, 8.81, and 12.8, respectively. This study demonstrated that CTS patients with DML less than 6.5 ms, DSL less than 5.7 ms, or 2L-INT less than 2.5 ms were good candidates for wrist splinting. Especially, the 2L-INT LD could be the most reliable indicator to predict clinical results for all grades of CTS. This electrophysiological information could be useful in further improvement of accurate diagnosis of CTS, and may help in the assessment of appropriate treatment for CTS with wrist splinting.

Impact of smoking and preoperative electrophysiology on outcome after open carpal tunnel release

BACKGROUND

The aim was to evaluate the influence of smoking and preoperative electrophysiology on the outcome of open carpal tunnel release.

METHODS

This retrospective observational study evaluated the outcome in 493 patients (531 hands) primary operated for carpal tunnel syndrome. Data were collected from medical records, health evaluations, and QuickDASH questionnaires before surgery and 1 year after.

RESULTS

Smokers had a higher QuickDASH score preoperatively as well as postoperatively, but the change in total score did not differ. The odds of having a postoperative QuickDASH score >10 were 2.5 times higher in smoking patients than in non-smoking patients. In 124/493 patients (25%), no clinically significant improvement was seen. Normal and extreme preoperative electrophysiology values were associated with higher postoperative scores. No correlation was found between preoperative QuickDASH scores and preoperative electrophysiology values.

CONCLUSIONS

Smokers with carpal tunnel syndrome experience more symptoms preoperatively. Smokers have remaining symptoms after surgery. There is no correlation between preoperative QuickDASH scores and preoperative electrophysiology values. Patients with normal or near to normal preoperative electrophysiology results have limited improvement after surgery.

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.

Endoscopic release for severe carpal tunnel syndrome in octogenarians

PURPOSE

To investigate the clinical outcomes of endoscopic carpal tunnel release for severe carpal tunnel syndrome in octogenarians compared with a younger cohort.

METHODS

Fifty-five hands in 48 patients were enrolled in this study. There were 27 hands in 24 octogenarians and 28 hands in 24 patients in a younger group with average ages of 83 and 60 years, respectively. Postoperative follow-ups were 8.5 and 7.2 months, respectively. Clinical evaluation included documentation of subjective symptoms and Semmes-Weinstein testing before surgery, 3 months after surgery, and at final follow-up. Symptom severity and function outcomes scores and compound muscle action potential of abductor pollicis brevis as an electrophysiological assessment were evaluated before surgery and at the final follow-up.

RESULTS

Nocturnal pain and paresthesias were improved in all patients. The octogenarians had poorer recovery of Semmes-Weinstein testing score and better improvement of outcomes scores than the younger group. There was no difference of the results in postoperative electrophysiological improvement between the groups.

CONCLUSIONS

Endoscopic release for severe carpal tunnel syndrome relieved symptoms and improved activities of daily living in octogenarians.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions

PURPOSE

To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.

METHODS

A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.

RESULTS

Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.

CONCLUSIONS

Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Comparative responsiveness of the Hand 20 and the DASH-JSSH questionnaires to clinical changes after carpal tunnel release

This study compared the responsiveness of the Hand 20 and the Japanese version of the disabilities of the arm, shoulder and hand (DASH-JSSH) questionnaires in carpal tunnel syndrome. The scores before and 3 months after surgery were used to calculate the standardized response mean and effect size. Of 57 patients enrolled in the study, 13 underwent open carpal tunnel release and 44 had endoscopic carpal tunnel release. The standardized response mean and the effect size of the Hand 20 scale were 0.60 and 0.54, respectively, and those of the disabilities of the arm, shoulder and hand scale were 0.39 and 0.36, respectively. Compared with the Disabilities of the Arm, Shoulder and Hand questionnaire, the Hand 20 questionnaire appears to have better responsiveness for assessing the effect of treatment by carpal tunnel release.

Pain and carpal tunnel syndrome

PURPOSE

Pain is not a classical symptom of carpal tunnel syndrome (CTS), with the exception of numbness that is so intense that it is described by patients as painful. The primary aim of our study was to determine which factors correlated with pain for patients diagnosed with CTS.

METHODS

We prospectively assessed all patients diagnosed with CTS in our unit over a 1-year period. We recorded demographic details for all patients, including past medical history, body mass index, smoking, and occupation. The diagnosis and severity of carpal tunnel syndrome were established through a combination of history, clinical assessment, and nerve conduction studies. Of 275 patients diagnosed and treated for CTS, 183 were women (67%), the mean age was 55 years (range, 22-87 y), and 166 cases were bilateral (60%). The mean body mass index was 29.5 kg/m2 (range, 17-48 kg/m2), and 81 patients smoked (30%). Patients completed a Short Form-McGill pain questionnaire (SF-MPQ) as a measure of pain at initial presentation. We assessed outcome 1 year after intervention using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score.

RESULTS

We found no association between pain according to the SF-MPQ and the positive clinical signs of CTS or positive nerve conduction studies. Multivariate analysis demonstrated that smoking and bilateral disease independently correlated with the overall SF-MPQ, with similar findings on subanalysis. Independent factors associated with an increased improvement in the QuickDASH at 1 year were the presentation QuickDASH score, positive nerve conduction studies, and smoking.

CONCLUSIONS

The only independent factors that correlated with pain at presentation of CTS were smoking and bilateral disease. Pain according to the SF-MPQ was not associated with classical clinical findings of the disease or with positive findings on nerve conduction testing.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

How to measure outcomes of peripheral nerve surgery

Evaluation of outcomes after peripheral nerve surgeries include several assessment methods that reflect different aspects of recovery, including reinnervation, tactile gnosis, integrated sensory and motor function, pain and discomfort, and neurophysiologic and patient-reported outcomes. This review lists measurements addressing these aspects as well as the advantages and disadvantages of each tool. Because of complexities of neurophysiology, assessment remains a difficult process, which requires researchers to focus on measurements best relevant to specific conditions and research questions.

Second lumbrical-interossei nerve test predicts clinical severity and surgical outcome of carpal tunnel syndrome

The purpose of this study was to examine the utility of the second lumbrical-interossei nerve (2L-IN) test in the diagnosis of carpal tunnel syndrome (CTS). We examined 65 patients with suspected unilateral CTS using the 2L-IN test, in addition to the standard electrophysiological test. The operative cases were divided into three classes of severity based on Padua's neurophysiological classification: extreme CTS (absence of median motor and sensory response); severe CTS (absence of sensory response, abnormal distal motor latency [DML]); and moderate CTS (abnormal sensory nerve conduction velocity, abnormal DML). With the 2L-IN test, the extreme CTS group could be further subdivided into extreme CTS-A (both abductor pollicis brevis [APB]- compound muscle action potential [CMAP] and 2L-CMAP not recordable) and extreme CTS-B (2L-CMAP recordable, APB-CMAP not recordable). Patients with extreme CTS and severe CTS were older, had chronic symptoms, and poorer outcome compared with the moderate CTS patients. Patients of the moderate CTS group were almost all satisfied with the results of surgery. The electrodiagnostic severity correlated with the clinical outcome. Severe strangulation of the thenar muscle branch was identified in patients in the extreme CTS-B group, requiring decompression of the thenar muscle branch rather than conventional simple transverse ligament detachment.

The relationship between neuropathic pain, and the function of the upper limbs based on clinical severity according to electrophysiological studies in patients with carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is an entrapment neuropathy of the median nerve, and CTS can cause neuropathic pain. The aim of this study was to evaluate the relationship between neuropathic pain, function of the upper limb, and the electrophysiology in patients with CTS. The terminal latency of median nerve was measured in 34 patients diagnosed with CTS, and they were asked to fill out the Japanese Society for Surgery of the Hand version of the Disability of Arm, Shoulder, and Hand questionnaire (DASH-JSSH) as the patient's assessment of the function of upper limbs and pain DETECT as an assessment for neuropathic pain. There was no significant correlation between the terminal latency and the pain DETECT score, or the terminal latency and the DASH-JSSH score. However, there was a significant correlation between the pain DETECT and DASH-JSSH scores. Neuropathic pain affects the function of the upper extremities in patients with CTS.

Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation

The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.