The quality and strength of evidence for etiology: example of carpal tunnel syndrome

Relationship between Gravidity, Parity, and Neurophysiological Features in Carpal Tunnel Syndrome (CTS) Patients with a History of Pregnancy

BACKGROUND

It is not yet clear if gravidity and parity have any relationships with the electrodiagnostic parameters of carpal tunnel syndrome (CTS).

OBJECTIVE

To determine whether there is a relationship between electrodiagnostic findings, gravidity, and parity number in CTS.

MATERIALS AND METHODS

Female patients over 18 years of age with CTS were included in this retrospective cohort study. The gravidity/parity number, median nerve compound muscle action potential (CMAP), and compound nerve action potential (CNAP) of the patients were analyzed. The two subgroups of the Boston carpal tunnel syndrome questionnaire (BCTSQ): The Symptom Severity Scale (SSS) and Functional Severity Scale (FSS) were applied to the patients. CTS patients were divided into two groups aged at first pregnancy ≤20 years and >20 years.

RESULTS

One hundred and eight CTS extremities (seven right-sided CTS, three left-sided CTS, 49 bilateral CTS) of 59 patients were included. The median (interquartile range: 25%-75%) number of gravidity, parity, and abortion were 3 (2-5), 3 (2-4), and 0 (0-0), respectively. Right-sided CTS patients at the age of first pregnancy ≤20 years had higher BCTSQ-SSS/FSS scores and median nerve CMAP latency compared to patients at the age of first pregnancy >20 years (P = 0.029 for SSS; P = 0.042 for FSS; and P = 0.041 for CMAP latency). A negative correlation was found between the gravidity/parity numbers and median nerve CNAP/CMAP amplitudes (P = 0.028/0.031, r = -0.293/-0.289 for CNAP amplitude; and P = 0.006/0.035, r = -0.363/-0.283 for CMAP amplitude).

CONCLUSION

Neurophysiological findings worsen as the number of gravidity and parity increase. Electrodiagnostic and clinical features of CTS may be worsening in females below 20 years at first pregnancy.

A Proposal for Neurography Referral in Patients with Carpal Tunnel Syndrome Based on Clinical Symptoms and Demographic Variables of 797 Patients

The clinical manifestation of median nerve entrapment at the carpal tunnel level is known as carpal tunnel syndrome (CTS). Electroneurography (ENG) is considered the gold standard in CTS evaluation. We conducted a retrospective study and analyzed some clinical and demographic variables, relating them to the degree of neuropathy using ENG, to better understand the role of ENG in this very common disease. We studied 816 patients referred to our service for neurographic evaluation. Their symptoms were classified as compatible with CTS (cCTS) (n = 646) and atypical for CTS (aCTS) (n = 170). A blind ENG was performed on 797 patients. Patient characteristics were coded as variables and analyzed to study whether they could predict neuropathy severity (sensory and motor involvement or grade ≥ 3 in our classification). We found a correlation between typical symptomatology, age over 50 years, male gender, positivity of Phalen's maneuver and Tinel's sign, and a neuropathy grade ≥ 3. We also found a correlation with CTS in the contralateral hand if the other hand showed neuropathy, despite the lack of symptoms in this hand. We propose a practical algorithm for ENG referral based on clinical symptoms, demographic factors, and neurophysiological variables.

Surgery for mononeuropathies

Advancement in microsurgical techniques and innovative approaches including greater use of nerve and tendon transfers have resulted in better peripheral nerve injury (PNI) surgical outcomes. Clinical evaluation of the patient and their injury factors along with a shift toward earlier time frame for intervention remain key. A better understanding of the pathophysiology and biology involved in PNI and specifically mononeuropathies along with advances in ultrasound and magnetic resonance imaging allow us, nowadays, to provide our patients with a logical and sophisticated approach. While functional outcomes are constantly being refined through different surgical techniques, basic scientific concepts are being advanced and translated to clinical practice on a continuous basis. Finally, a combination of nerve transfers and technological advances in nerve/brain and machine interfaces are expanding the scope of nerve surgery to help patients with amputations, spinal cord, and brain lesions.

Management of Failed Carpal and Cubital Tunnel Release: An Evidence-Based Guide to Success

Carpal tunnel and cubital tunnel syndromes are the most common compressive neuropathies of the upper extremity with surgical treatment having high success rates for both conditions. Although uncommon, persistent or recurrent carpal and cubital tunnel syndrome presents a challenge for patients and providers. Diagnosis of persistence versus recurrence of the pathology is key in establishing an appropriate treatment plan to provide the best possible patient outcomes. After an established diagnosis, a wide array of treatment options exist which varies based on previous procedures performed. This review discusses relevant anatomy, etiology, and clinical presentations of persistent and recurrent carpal and cubital tunnel syndromes. The range of treatment options is presented based on history and diagnostic findings. Treatment options span from revision of nerve decompression to the use of soft tissue rearrangement procedures. Some specific treatment options discussed include simple revision nerve decompression, external neurolysis, soft tissue rearrangement, such as the hypothenar fat flap or various transposition techniques, and the use of nerve wraps. Included is an evidence-based management guide for diagnosis and treatment of persistent versus recurrent carpal and cubital tunnel syndromes.

Endothelial nitric oxide synthase Asp298Glu (894G/T) gene polymorphism as a possible risk factor for the coronary slow flow phenomenon among Iranians

Background

Mounting evidence indicates an association between endothelial dysfunction and the coronary slow flow phenomenon (CSFP). In the present study, we aimed to evaluate the possible role of endothelial nitric oxide synthase (eNOS) 894G/T and interleukin-1β (IL-1β) 315C/T polymorphisms as possible risk factors for CSFP.

Methods

This prospective study enrolled patients with CSFP and individuals with normal coronary arteries. Genotypes were assessed using regular polymerase chain reaction and direct Sanger-sequencing techniques.

Results

The study population consisted of 267 individuals: 180 patients with CSFP (49 women [27.2%]) at a median age of 55 (48–62) years and 87 controls with normal coronary arteries (56 women [64.4%]) at a median age of 47 (41–58) years. The allelic distribution of eNOS 894G/T was significantly associated with CSFP (odds ratio [OR], 1.58; 95% confidence interval (CI), 1.04–2.42; P = 0.03). This polymorphism increased the risk of CSFP under the dominant model (OR 1.73; 95% CI I.02–2.95; P = 0.04). However, the allelic frequencies (1.05; 95% CI 0.68–1.59; P = 0.83) and genotypic frequencies (0.88; 95% CI 0.52–1.49; P = 0.63) of the IL-1β 315C/T polymorphism were not associated with the incidence of CSFP in the Iranian population.

Conclusions

The CSFP and control groups were statistically different regarding the eNOS 894G/T polymorphism. Our findings also demonstrated that the IL-1β 315C/T polymorphism was not a risk factor for CSFP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02736-0.

A 15-Year Review of Clinical Practice Patterns in Carpal Tunnel Syndrome Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery has been collecting practice data on carpal tunnel syndrome treatment since 2004 as part of its Continuous Certification Program. These data allow plastic surgeons to compare their surgical experience to national trends and analyze those trends in relation to current evidence-based medicine.

METHODS

Data on carpal tunnel syndrome treatment from 2004 to 2014 were compared to those from 2015 to 2020. National practice trends observed in these data were evaluated relative to current literature regarding evidence-based practices.

RESULTS

A total of 11,090 carpal tunnel syndrome cases were included from 2004 to 2020. Electrodiagnostic and imaging studies were performed on most patients despite adding little sensitivity and specificity when physical examination tests are performed and not being considered cost-effective. An open "mini" approach has remained the most common surgical technique in carpal tunnel release for the last 15 years, with growing usage (53 percent versus 59 percent, p < 0.001). Splinting has decreased significantly over the last 15 years, from usage in 39 percent of patients to 28 percent (p < 0.001). Formal postoperative hand therapy has declined from 27 percent of patients to 22 percent (p < 0.001). Despite their low efficacy, 63 percent of patients received one or more perioperative doses of antibiotics.

CONCLUSIONS

Analysis of the Continuous Certification Program tracer data from the American Board of Plastic Surgery provides an excellent overview of current practice and its development over the 15 years since its inception. This analysis provides insight into how effectively plastic surgeons have remained aligned with developments in best practices in treating carpal tunnel syndrome.

Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability

BACKGROUND

Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity.

QUESTION/PURPOSE

What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale?

METHODS

One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings.

RESULTS

After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 [95% confidence interval 7.7 to 15]), longer duration of symptom episodes (OR 4.5 [95% CI 3.3 to 6.2]), nocturnal numbness in spite of splint immobilization (OR 3.2 [95% CI 2.3 to 4.3]), constant numbness (OR 2.5 [95% CI 1.9 to 3.4]), positive Tinel and positive Phalen test results (OR 2.2 [95% CI 1.6 to 2.9]), and older age (OR 1.6 [95% CI 1.2 to 2.1]).

CONCLUSION

Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability.

CLINICAL RELEVANCE

Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability.

Carpal Tunnel Syndrome and Calcium Deposit in the Surgically Transacted Transverse Carpal Ligament

A diagnosis of carpal tunnel syndrome (CTS) in a human often contains more than one test. Calcification of the traverse carpal ligament (TCL) is the common reason why patients seek CTS surgery. However, the determination of calcium (Ca) concentration in the TCL has not been studied. The results of environmental toxicity studies assessing the relationship between Ca and elemental deposition in the TCL are inconsistent. The purpose of this paper was to verify this hypothesis by conducting a chemical analysis of a portion of the released TCL to assess whether there is a relationship between CTS and Ca, measured as the total concentration of Ca, and to measure the precipitation of elements; the most closely related elements associated with Ca are cadmium and lead, which are also toxic. Surgical release of TCL was performed on forty patients. Total concentrations of Ca, Cd, and Pb in the extracted portion of TCL were digested and determined using inductively coupled plasma mass spectrometry (ICP-MS) and the possibility of using X-ray spectroscopy (XRF) for direct elemental analysis. Ca mineralisation was revealed in some TCLs. In assessing patients' environmental pollution, it was observed that the Cd and Pb concentrations were significant with a higher Ca concentration, and XRF was useful for direct detection of the elements in samples of the human body. These results indicate that TCL mineralisation by Ca does not characterise CTS, which has important concerns in improving patients' therapeutic strategies, and Cd and Pb concentrations varied due to different factors.

Ultrasound of Median Nerve in the Diagnosis of Carpal Tunnel Syndrome—Correlation with Electrophysiological Studies

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy caused by impairment of the median nerve due to compression as it passes through the carpal tunnel.

The current gold standard in diagnosing CTS and nerve damage is by electrophysiological nerve conduction study (NCS). However, 10 to 25% of NCS results are falsely negative. Moreover, NCS remains an expensive and time-consuming procedure for patients. Ultrasonography serves as a real-time, well-tolerated, portable, and noninvasive tool for assessing the carpal tunnel.

This study aims to assess the role of high-frequency ultrasound of the median nerve at the wrist in evaluating CTS and correlate with NCS to determine whether sonography can be used as an alternative to NCS in diagnosing and grading CTS.

Identifying Risk Factors for Recurrence After Cubital Tunnel Release

PURPOSE

This study investigated specific risk factors for recurrent surgery of ulnar nerve entrapment (ie, ipsilateral clinical symptoms within 5 years after initial cubital tunnel release [CuTR]) in a large cohort. We hypothesized that recurrence is associated with lifestyle variables (eg, smoking, drinking alcohol, a high body mass index [BMI]) or comorbidities).

METHODS

A retrospective cohort study was performed using the Current Procedural Terminology codes for all patients who underwent CuTR between January 2012 and November 2018. Demographic data, including sex, age, weight, height, BMI, comorbidities, smoking, and alcohol consumption, were collected. The primary outcome was the need for revision surgery after initial CuTR. Univariate and multivariate analyses were performed to identify potential risk factors for revision surgery.

RESULTS

Of the 678 patients who underwent CuTR, 120 patients (18%) needed revision surgery within 5 years. Sixty-six patients required subfascial transposition (55%) and 47 patients (39%) received in situ releases. Also, sex, BMI, smoking, alcohol consumption, and comorbidities (except for spinal disc herniation) were similar between the primary and revision subgroup. Age at first occurrence was significantly lower in the revision group (48 years for revision vs 52 years for primary surgery). Moreover, cervical spinal disc herniation was associated with revision surgery (13% vs 6% in the primary group).

CONCLUSIONS

Age and medical history of cervical spinal disc herniation are associated with an increased risk of revision surgery. More importantly, BMI, smoking, alcohol consumption, and other comorbidities are not associated with increased risk of revision surgery within our sample.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Personal factors associated with carpal tunnel syndrome (CTS): a case-control study

BACKGROUND

Carpal tunnel syndrome (CTS) is one of the most common nerve entrapments in the upper limb. In Saudi Arabia, few studies have investigated CTS in the general population. This study aimed to determine the association between personal factors and CTS.

METHODS

A case-control study involved adults aged 18 and above. Cases were recruited from electrophysiology lab records as consecutive case series, while controls were individuals who were free of CTS symptoms according to the Boston Carpal Tunnel Questionnaire (BCTQ). The electronic medical records of participants were reviewed to obtain age, height, weight, medical conditions, and mobile numbers. Cases and controls were contacted via phone to complete a questionnaire that was designed based on previous literature. We used multivariate binary logistic regression to identify the personal factors significantly associated with CTS.

RESULTS

A total of 95 cases and 190 controls were included. Most of the participants were female (84.2%) and Saudi (93%). Most of cases were above 45 years of age (73.7%), while 84.7% were 45 year - old or younger among the control group. Stratified logistic regression showed that performance of household chores was significantly associated with CTS. While physical exercise associated with decreased odds of CTS.

CONCLUSIONS

This study adds to the body of evidence on personal factors associated with CTS. However, the degree of differences in the age structure of the cases compared with the controls suggest that there is a considerable potential for residual confounding affecting the results.

TRIAL REGISTRATION NUMBER

Not applicable.

Replication of epidemiological associations of carpal tunnel syndrome in a UK population-based cohort of over 400,000 people

Introduction

Several phenotypic factors are associated in the literature with an increased risk of carpal tunnel syndrome (CTS). Along with female sex and older age, certain systemic diseases show an association with CTS, with varying degrees of evidence.

Methods

This study was performed using the UK Biobank resource – a cohort study of over 500,000 participants who have allowed linkage of phenotypic data with their medical records. We calculated the prevalence of CTS and a sex-specific prevalence ratio and compared the body mass index (BMI) between cases and controls. We performed a series of nested case-control studies to compute odds ratios for the association between CTS and three systemic diseases.

Results

There were 12,312 CTS cases within the curated UK Biobank dataset of 401,656 (3.1% prevalence), and the female:male ratio was 1.95:1. CTS cases had, on average, a BMI > 2.0 kg/m² greater than controls. Odds ratios for the association with CTS for three systemic diseases were 2.31 (95% CI 2.17–2.46) for diabetes, 2.70 (95% CI 2.44–2.99) for rheumatoid arthritis, and 1.47 (95% CI 1.38–1.57) for hypothyroidism. Adjusted for BMI, these odds ratios fell to 1.75 (95% CI 1.65–1.86), 2.43 (95% CI 2.20–2.69), and 1.35 (95% CI 1.26–1.43), respectively.

Discussion

We harnessed the size and power of UK Biobank to provide robust replication of evidence for the associations between CTS and female sex, raised BMI, and three systemic diseases, which are only mediated in part by raised BMI.

Most YouTube Videos About Carpal Tunnel Syndrome Have the Potential to Reinforce Misconceptions

BACKGROUND

Studies of online health information have addressed completeness and adherence to evidence, which can be difficult because current evidence leaves room for debate about etiology, diagnosis, and treatment. Fewer studies have evaluated whether online health information can reinforce misconceptions. It can be argued that information with the potential to harm health by reinforcing unhelpful misconceptions ought to be held to a higher standard of evidence.

QUESTIONS/PURPOSES

(1) What is the prevalence and nature of health information in YouTube videos with the potential to reinforce common misconceptions about symptoms and treatment associated with carpal tunnel syndrome (CTS)? (2) What factors (such as the number of views, likes, and subscribers) are associated with Potential Reinforcement of Misconception scores of YouTube videos about CTS?

METHODS

After removing all personalized data, we searched for the term "carpal tunnel syndrome" on YouTube, reviewed the first 60 English-language videos that discussed the diagnosis and treatment of CTS, and collected available metrics. The primary outcome was the number of statements that could reinforce misconceptions about CTS, rated by two authors using a checklist. As a secondary outcome, we counted the number of statements that could help patients by reorienting or balancing common misconceptions, providing agency, and facilitating decisions, and we subtracted the number of potential misconceptions from this count. A modified version of the DISCERN instrument (a validated scoring system designed to gauge the quality and reliability of health information) was used to evaluate each video. We sought factors associated with the Potential Reinforcement of Misconception score-in both the negative-only and combined (positive and negative) variations-accounting for various YouTube metrics (such as the number of views, number of likes and dislikes, and duration) and the modified DISCERN score. The interrater reliability was excellent for both the Potential Reinforcement of Misconceptions checklist (ICC = 0.97; Pearson correlation [r] = 0.97) and DISCERN information quality score (ICC = 0.96; r = 0.97).

RESULTS

Seventy-eight percent of the YouTube videos (47 of 60 videos) contained at least one statement that could reinforce common misconceptions about CTS. The median number of potentially misconception-reinforcing statements was two (range one to three), with the most common statements being that CTS is caused by hand use (38%; 23 of 60 videos) and that splints can alter the natural history of the disease (37%; 22 videos). Videos that were more popular (higher number of views or likes) did not contain less potential reinforcement of misconceptions. In the multivariable analysis, we found a strong association between the DISCERN score and the CTS Potential Reinforcement of Misconceptions score (regression coefficient = 0.67; 95% CI 0.22-1.2; partial r2 = 0.13; p = 0.004) and a lower number of subscribers (calculated per one million subscribers: regression coefficient = -0.91; 95% CI -1.8 to -0.023; p = 0.045).

CONCLUSION

Potential reinforcement of misconceptions is prevalent in YouTube videos about CTS, more so in videos with lower information quality scores.

CLINICAL RELEVANCE

Online health information should be held to a standard of accuracy (alignment with best evidence), and where such evidence leaves room for debate, it should be held to a standard by which unhealthy misconceptions are not reinforced.

[Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potenzial mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Transthyretin Gene Mutation Associated with Familial Carpal Tunnel Syndrome in Sample of Iraqi Patients

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in upper limbs. It affects women more frequently than men. CTS can be caused by many different systemic diseases and local mechanical conditions and it had signs and symptoms due to compression of median nerve at the carpal tunnel in wrist.

OBJECTIVE

The present study aims to study whether Transthyretin (TTR) gene polymorphisms have association with the development of FCTS.

METHODS

Sixty-four patients suffering from CTS were enrolled in this controlled cross sectional study. For all, nerve conduction study was performed to prove the diagnosis of CTS and to classify its severity. The mean age of all patients was 44.9±7.8 years, 89.1 % were female, 37.5 % had mild type CTS and 40.7 % had right side CTS. 3 mL of peripheral blood was collected from all patients which is a labeled (EDTA) tube at -20 C° for DNA extraction to identify a particular SNP (rs28933979; 148G/A; V50M) that locates at position chr18:31592974 on the exon-2 region which is reported to be associated to the Carpal Tunnel Syndrome. Exon-2 of TTR gene was amplified using the PCR technique and subjected to be tested for presence of SNP by Restriction Fragment Length Polymorphism (RFLP) assay.

RESULTS AND CONCLUSION

According to genetic variation, the study cannot discover any TTR gene polymorphism that back to FCTS.

Effect of extracorporeal shock wave therapy on different severities of carpal tunnel syndrome

Background

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome worldwide.

Objective

The current work aimed at determining the effect of extracorporeal shock wave therapy (ESWT) on different severities of carpal tunnel syndrome.

Subjects and methods

Sixty patients with unilateral carpal tunnel syndrome were participated in this study. They were divided into three equal groups according to severity (mild, moderate, and severe). All patients received shock wave therapy one session per week, for 6 weeks. Nerve conduction studies (NCs) were done for the median nerve. Pinch dynamometer was used to measure the degree of lateral pinch power, and Visual Analogue Scale (VAS) was used to assess degree of pain and Ultrasonography analysis measured cross-sectional area (CSA) of median nerve for all patients at the beginning and at the end of the study.

Results

There was significant improvement (P < 0.05) in sensory conduction parameters, CSA, lateral pinch power, and VAS after shock wave therapy in all groups. Also, there was significant improvement in motor latency, motor, and sensory amplitudes after shock wave therapy in mild and moderate groups only (P < 0.05). In all group samples, results revealed a highly significant correlations (p < 0.001) between peak sensory latency (PSL) with VAS, CSA with motor latency (ML), CSA with PSL, CSA with VAS, CSA with lateral pinch, and ML with lateral pinch.

Conclusion

It is recommended to use ESWT as a conservative treatment in patients with different severities of CTS, except patients with severe motor affection.

Trial registration

PACTR201804003293116. Registered on 26 April 2018 as retrospective registration in the pan African clinical trial registry (www.pactr.org).

Radiographs and Corticosteroid Injections at a New Patient Visit for Care of Carpal Tunnel Syndrome and Ulnar Neuropathy at the Elbow

Introduction The benefit of radiographs or steroid injection for idiopathic carpal tunnel syndrome (CTS) or ulnar neuropathy at the elbow (UNE) is open to debate. We assessed: (1) Radiographs ordered and injections performed at a new patient visit for patients presenting with either idiopathic CTS or UNE; (2) The estimated payment reduction if we omit these interventions; and (3) Patient age, sex, geographic region, and work status associated with radiographs or injections at a new patient visit for patients presenting with either idiopathic CTS or UNE.

Materials and Methods Using a large database of commercial insurance claims, we identified patients with a new visit for either CTS (N = 9,522), UNE (N = 2,507), or both (N = 962; 8.7%). We identified injections and radiographs, and estimated total payments for these interventions. We created three multivariable logistic regression models for each diagnosis to identify factors associated with the interventions.

Results Nearly one third of patients had radiographs at a new patient visit (30% and 32% for idiopathic CTS and UNE, respectively). Nearly 10% of patients with CTS and 2.6% with UNE received an injection. Both radiographs and injections representing annual minimum payments of over $345,000 and $294,000, respectively. Among people with CTS, radiographs were independently more common in the South and less common in the West. Injection for CTS was associated with younger age; North, Central, and South regions; and retired employment status. For people with UNE, radiographs were independently associated with younger age; South or West region; and retired or working employment status. Injection for UNE was associated with retired employment status.

Conclusion The prevalence of radiographs and injections suggests opportunities for savings, which might benefit clinicians with bundled or capitated payments and patients with large copayments or deductibles. The observed variation may reflect debate about whether these interventions are worthwhile.

Level of Evidence Diagnostic; Retrospective Database Level III study.

Genetic Risk of Trigger Finger: Results of a Genomewide Association Study

BACKGROUND

Trigger finger, or stenosing tenosynovitis, is one of the most common conditions affecting the hand, yet its pathophysiology remains poorly understood, and genetic association studies of trigger finger are lacking. The purpose of this study was to identify single-nucleotide polymorphisms associated with trigger finger through a genomewide approach.

METHODS

The authors performed a case-control genomewide association study in the Partners HealthCare Biobank. Single-nucleotide polymorphism- and gene-based association analyses were carried out after quality control, imputation, and filtering.

RESULTS

Among 942 trigger finger cases and 24,472 controls, the authors tested 7,846,471 single-nucleotide polymorphisms for association with trigger finger. In the single-nucleotide polymorphism-based analysis, a single locus on chromosome 13 corresponding to KLHL1 met the genomewide significance threshold (lead single-nucleotide polymorphism rs59988404; OR, 1.74; 95 percent CI, 1.47 to 2.07; p = 1.99 × 10). After mapping, gene-based analysis demonstrated a significant association with POLE2 (p = 7.53 × 10) on chromosome 14. Among trigger finger cases, rs59988404 genotype was significantly associated with the total number of trigger finger procedures performed (p = 0.026).

CONCLUSIONS

In the first reported genomewide association study of trigger finger, the authors report significant associations of KLHL1 and POLE2 with risk of trigger finger. The authors' results may help to elucidate the pathophysiology of trigger finger and facilitate an individualized, precision-medicine treatment approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Mutations in COMP cause familial carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, affecting a large proportion of the general population. Genetic susceptibility has been implicated in CTS, but the causative genes remain elusive. Here, we report the identification of two mutations in cartilage oligomeric matrix protein (COMP) that segregate with CTS in two large families with or without multiple epiphyseal dysplasia (MED). Both mutations impair the secretion of COMP by tenocytes, but the mutation associated with MED also perturbs its secretion in chondrocytes. Further functional characterization of the CTS-specific mutation reveals similar histological and molecular changes of tendons/ligaments in patients’ biopsies and the mouse models. The mutant COMP fails to oligomerize properly and is trapped in the ER, resulting in ER stress-induced unfolded protein response and cell death, leading to inflammation, progressive fibrosis and cell composition change in tendons/ligaments. The extracellular matrix (ECM) organization is also altered. Our studies uncover a previously unrecognized mechanism in CTS pathogenesis.

Familial carpal tunnel syndrome (CTS) is common, but causal genes are not characterized. Here the authors report two CTS-related mutations in two large families that impair secretion of COMP in tenocytes, leading to ER stress-induced unfolded protein response, inflammation and fibrosis in patients and mouse models.

Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Non-operative Treatment of Carpal Tunnel Syndrome

PURPOSE OF REVIEW

To determine the current evidence for various non-operative therapies in the treatment of carpal tunnel syndrome RECENT FINDINGS: Multiple non-operative treatment modalities exist in the treatment of mild to moderate carpal tunnel syndrome. While certain modalities such as splinting and corticosteroid injections have moderate- to high-quality evidence to support use, other less commonly used treatments have fewer therapeutic indications in the current literature. Healthcare providers should be able to initiate the appropriate diagnostic evaluation and assess the utility of non-operative therapies in the treatment of carpal tunnel syndrome. Moreover, healthcare providers should also be able to understand the evidence behind each treatment and the indications for surgical intervention.

Functional Outcomes of 300 Carpal Tunnel Release: 1.5 cm Longitudinal Mini-incision

Objective

There is an opportunity for median nerve decompression by open surgery in carpal tunnel syndrome which is the most common surgical procedure in neurosurgical practice. The aim of this study is to evaluate the long-term outcomes of carpal tunnel release with 1.5 cm longitudinal mini-incision technique with regarding the effectiveness and safety.

Methods

For this prospective study, 300 hands for 188 patients with advanced carpal tunnel syndrome who had indication for neurolysis underwent carpal tunnel release through a 1.5 cm longitudinal mini-incision between March 2011 and 2015. There were 132 (70%) females and 56 (30%) males with a mean age of 40 ± 29.5 years (ranging from 24 to 73) and female to male: About 2.56.178 operations were performed for the right hand and 122 for the left hand. Preoperatively, all patients were evaluated with clinical examination and nerve conduction studies. The clinical effects of the patients assessed with the Global Symptom Score (GSS) and Visual Analog Patient Satisfaction Scale.

Results

The mean follow-up period was 18.6 ± 9.3 months (12-30 months). Postoperatively, 2% (six hands) complained of residual mild pain with tenderness of scar and only 1% (three hands) complained of median nerve damage (neuropraxy) with tingling and numbness but was temporary which improved after 1 week. Five patients (seven hands) loosed strength of their wrists, but muscle force of abductor pollicis brevis reinforced after 1 month. There is no evidence of local infection, stiffness, loss of some wrist strength, or recurrence of the disorder. Postoperative GSS scoring obviously improved than preoperative (P < 0.002). There is no patient who underwent reoperation. The mean time recovery appeared almost 2 weeks.

Conclusion

1.5 cm longitudinal mini-incision method in carpal tunnel syndrome decompression showed satisfactory pain relief, wound healing, and nontender scar with good functional outcomes. The technique was performed safely without major complication.

Prospective Pilot Study Comparing Pre- and Postsurgical CTSAQ and Neuro-QoL Questionnaire with Median Nerve High-Resolution Ultrasound Cross-Sectional Areas

PURPOSE

The aims of this study were (1) to assess the utility of the Quality of Life in Neurological Disorder (Neuro-QoL) questionnaire in patients with carpal tunnel syndrome by comparing the validated patient-reported outcome (PRO) measure Neuro-QoL to the validated Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) before and following carpal tunnel release, (2) to compare the measurements of the median nerve cross-sectional area (CSA) using high-resolution ultrasound (HRUS) before and after surgery, and (3) to determine a correlation between HRUS and PRO.

METHODS

Individuals diagnosed with carpal tunnel syndrome were evaluated using the CTSAQ, Neuro-QoL, and HRUS before surgery and at 3 months after surgery.

RESULTS

Twenty patients completed the study. Overwhelmingly, there was an improvement in symptoms and function assessed by patients on both the Neuro-QoL and the CTSAQ at 3 months after surgery. The Neuro-QoL Physical Function and Upper Extremity scores had strong correlation with the CTSAQ activity score but had low to moderate correlation with the CTSAQ symptoms score, before and after surgery. The HRUS measurements of the median nerve at the carpal tunnel inlet demonstrated a decrease in CSA whereas no noticeable changes were observed at mid tunnel and at the outlet (hook of hamate). The correlations between the ultrasound findings and PRO measures ranged from weak to strong.

CONCLUSIONS

Patients had resolution of symptoms and higher physical function following carpal tunnel release measured by both the CTSAQ and the Neuro-QoL scores. The Neuro-QoL self-assessment questionnaire, a measurement of quality of life, correlated well with the CTSAQ. Therefore, it could be used as a self-assessment outcomes tool in patients undergoing carpal tunnel release. At 3 months after surgery, HRUS measurements of the median nerve CSA showed a noticeable decrease of CSA only at the inlet of carpal tunnel. This objective improvement correlated with the improvement in CTSAQ and Neuro-QoL scores.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnosis II.

Work-Related Musculoskeletal Injuries in Plastic Surgeons in the United States, Canada, and Norway

BACKGROUND

Musculoskeletal injuries are more common among surgeons than among the general population. However, little is known about these types of injuries among plastic surgeons specifically. The authors' goals were to evaluate the prevalence, nature, causes, and potential solutions of these musculoskeletal injuries among plastic surgeons in three different countries: the United States, Canada, and Norway.

METHODS

A survey was e-mailed to plastic surgeons in the United States, Canada, and Norway, soliciting their demographics, practice description, history of musculoskeletal issues, potential causes of these symptoms, and proposed suggestions to address these injuries. The prevalence of various musculoskeletal symptoms was calculated, and predictors of these symptoms were evaluated using multivariate logistic regression.

RESULTS

The survey was sent to 3314 plastic surgeons, with 865 responses (response rate, 26.1 percent); 78.3 percent of plastic surgeons had musculoskeletal symptoms, most commonly in the neck, shoulders, and lower back. U.S. surgeons were significantly more likely to have musculoskeletal symptoms than Norwegian surgeons (79.5 percent versus 69.3 percent; p < 0.05); 6.7 percent of all respondents required surgical intervention for their symptoms. The most common causative factors were long surgery duration, tissue retraction, and prolonged neck flexion. The most common solutions cited were core-strengthening exercises, stretching exercises, and frequent adjustment of table height during surgery.

CONCLUSIONS

Plastic surgeons are at high risk for work-related musculoskeletal injuries. Ergonomic principles can be applied in the operating room to decrease the incidence and severity of those injuries, and to avoid downstream sequelae, including the need for surgery.

Concurrent musculoskeletal and soft tissue pain in the upper extremity can affect the treatment and prognosis of carpal tunnel syndrome: redefining a common condition

Objective

To demonstrate the importance of recognizing and separating nonmedian nerve-related symptoms from those related to median nerve compression at the carpal tunnel.

Methods

The records of 80 patients, aged 31–82 years (39 males and 41 females), who had undergone median nerve decompression using open and endoscopic release surgery, were reviewed. Peripheral electrodiagnostic studies were performed in all patients prior to surgery. Those whose nonmedian nerve-related symptoms, also known as musculoskeletal and soft tissue pain and tenderness, persisted postoperatively, were referred to another electrodiagnostic study to reassess the median nerve function at the carpal tunnel. Peripheral electrodiagnostic studies were deemed unnecessary for patients with exclusively median nerve-related symptoms who improved dramatically following surgery. Included from the study were cases whose presenting symptoms were primarily referrable to median nerve dysfunction with or without associated musculoskeletal pain. Cases that were excluded were those whose symptoms were related to various primary conditions. Outcome of surgery was reviewed and correlated with symptoms related to median nerve compression and musculoskeletal irritation, and with electrodiagnostic abnormalities.

Results

Complete resolution of symptoms, following surgery, occurred in patients with clinical and electrophysiologic signs of median nerve compression but without significant symptoms of musculoskeletal irritation. Those with concurrent and prominent musculoskeletal and soft tissue pain had variable results, both favorable and unfavorable, including three who developed signs and symptoms of complex regional pain syndrome.

Conclusion

The symptoms related to median nerve compression at the carpal tunnel and the symptoms related to musculoskeletal and soft tissue irritation are two different symptom complexes that have important diagnostic and therapeutic considerations. We would like to propose that “true carpal tunnel syndrome” symptoms, those that are exclusively median nerve related, should be considered a distinct entity. When musculoskeletal and soft tissue pain is more prominent and dominates the overall clinical presentation, the term “mechanical stress syndrome” is more appropriate.

Carpal tunnel syndrome: The role of collagen gene variants

INTRODUCTION

The direct causes of idiopathic carpal tunnel syndrome (CTS) are still unknown. It is suggested that pathology of the tendons and other connective tissue structures within the carpal tunnel may play a role in its aetiology. Variants in genes encoding connective tissue proteins, such as type V collagen, have previously been associated with CTS. Since variants within other collagen genes, such as type I, XI and XII collagen, have previously been associated with modulating the risk of musculoskeletal soft tissue injuries, the aim of this study was to determine whether variants within COL1A1, COL11A1, COL11A2 and COL12A1 were associated with CTS.

METHODS

Self-reported Coloured South African participants, with a history of carpal tunnel release surgery (CTS, n=103) and matched control (CON, n=150) participants without any reported history of CTS symptoms were genotyped for COL1A1 rs1800012 (G/T), COL11A1 rs3753841 (T/C), COL11A1 rs1676486 (C/T), COL11A2 rs1799907 (T/A) and COL12A1 rs970547 (A/G).

RESULTS

The TT genotype of COL11A1 rs3753841 was significantly over-represented in the CTS group (21.4%) compared to CON group (7.9%, p=0.004). Furthermore, a trend for the T minor allele to be over-represented in the CTS group (p=0.055) with a significant association when only female participants (p=0.036) were investigated was observed. Constructed inferred pseudo-haplotypes including a previously investigated COL5A1 variant, rs71746744 (-/AGGG), suggest gene-gene interactions between COL5A1 and COL11A1 modulate the risk of CTS.

DISCUSSION

These findings provide further information of the role of the genetic risk factors and the possible role of variations in collagen fibril composition in the aetiology of CTS. Genetic factors could potential be included in models developed to identify indivisuals at risk of CTS. Strategies that target modifiable risk factors to mitigate the effect of non-modifiable risk factors, such as the genetic risk, could be also developed to reduce incidence and morbidity of CTS.

[Spanish validation of the Boston Carpal Tunnel Questionnaire]

INTRODUCTION AND OBJECTIVE

To describe the process of cultural adaptation and validation of the Boston Carpal Tunnel Questionnaire (BCTQ) measuring symptom intensity, functional status and quality of life in carpal tunnel syndrome patients and to report the psychometric properties of this version.

MATERIAL AND METHODS

A 3 expert panel supervised the adaptation process. After translation, review and back-translation of the original instrument, a new Spanish version was obtained, which was administered to 2 patient samples: a pilot sample of 20 patients for assessing comprehension, and a 90 patient sample for assessing structural validity (factor analysis and reliability), construct validity and sensitivity to change. A re-test measurement was carried out in 21 patients. Follow-up was accomplished in 40 patients.

RESULTS

The questionnaire was well accepted by all participants. Celling effect was observed for 3 items. Reliability was very good, internal consistency: αS=0.91 y αF=0.87; test-retest stability: rS=0.939 and rF=0.986. Both subscales fitted to a general dimension. Subscales correlated with dynamometer measurements (rS=0.77 and rF=0.75) and showed to be related to abnormal 2-point discrimination, muscle atrophy and electromyography deterioration level. Scores properly correlated with other validated instruments: Douleur Neuropatique 4 questions and Brief Pain Inventory. BCTQ demonstrated to be sensitive to clinical changes, with large effect sizes (dS=-3.3 and dF=-1.9).

CONCLUSIONS

The Spanish version of the BCTQ shows good psychometric properties warranting its use in clinical settings.

Association between work-related biomechanical risk factors and the occurrence of carpal tunnel syndrome: an overview of systematic reviews and a meta-analysis of current research

BACKGROUND

Occupational risks for carpal tunnel syndrome (CTS) have been examined in various occupations, and several systematic reviews (SRs) have been published on this topic. There has been no critical appraisal or synthesis of the evidence in the SRs. The aims of this study are (1) to synthesise the observational evidence and evaluate the methodological quality of SRs that assess the effect of biomechanical risk factors on the development of CTS in workers, (2) to provide an update of current primary research on this association, (3) to assess a potential dose-response relationship.

METHODS

We searched MEDLINE, EMBASE, CINAHL, the Cochrane Library and the reference lists of articles. The first step covered SRs (1998-2014), and the second step covered current primary studies (2011-2014). The methodological quality of the SRs was evaluated by using the AMSTAR-R tool; primary studies were assessed using a list of 20 items. A qualitative approach was used for synthesising evidence. In addition, we undertook a meta-analysis of the primary studies to determine risk ratios in the dose-response relationship.

RESULTS

We identified ten SRs that covered a total of 143 original studies. Seven primary studies met the criteria for inclusion, of which four provided longitudinal data. We found high quality of evidence for risk factors such as repetition, force and combined exposures. Moderate quality of evidence was observed for vibration, and low quality of evidence was found for wrist postures. An association between computer use and CTS could not be established. Recent primary studies supported the existence of a significant relationship between CTS and repetition, force and combined exposure. The meta-analysis of current research revealed a dose-response relationship between CTS and the American Conference of Governmental Industrial Hygienists' (ACGIH) threshold limit value (TLV) for hand-activity level (HAL). Those between the action limit and TLV and above TLV had RR of 1.5 (95% CI 1.02-2.31) and RR 2.0 (95% CI 1.46-2.82), respectively.

CONCLUSIONS

Occupational biomechanical factors play a substantial role in the causation of CTS. Data from current primary studies on dose-response suggest that the risk of CTS increases with the ACGIH TLV levels.

The benefit of carpal tunnel release in patients with electrophysiologically moderate and severe disease

PURPOSE

To compare change in numbness and pain after carpal tunnel release in patients with electrophysiologically moderate and severe disease.

METHODS

We tested the primary null hypothesis that there is no difference in the total Carpal Tunnel Symptoms Scale score 3 months after surgery between patients with moderate and those with severe disease. Ninety-five patients (47 in the moderate cohort, and 48 in the severe cohort) who had miniopen carpal tunnel release between November 2011 and November 2013 were identified from our prospectively collected database. For each patient, the total Carpal Tunnel Symptoms Scale score, as well the numbness and pain subscale scores, at the preoperative and postoperative (2-wk, 1-mo, 2-mo, 3-mo, ≥ 1-y) visits were documented. The data were analyzed with repeated-measures analysis of variance.

RESULTS

Three months after surgery, patients with moderate carpal tunnel syndrome (CTS) reported, on average, no symptoms, and patients with severe disease had reduced but unresolved symptoms. Although symptoms diminished in both groups from the preoperative assessment to the 2-week postoperative assessment, patients with severe CTS had comparatively more severe symptoms at all time points with the exception of pain at 2 weeks and 1 year or longer after surgery, at which times there was no significant difference. At 1 year or longer after surgery, 1 (2%) patient with moderate CTS and 9 (19%) patients with severe CTS reported continued symptoms. Preoperative electrodiagnostic severity was the factor most predictive of symptom scores.

CONCLUSIONS

Patients with severe CTS experience considerable reduction in symptoms after surgery but should be informed that recovery may be more prolonged and, in some cases, incomplete 1 year after carpal tunnel release, particularly with regard to numbness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Carpal tunnel syndrome: assessment of surgeon and patient preferences and priorities for decision-making

PURPOSE

This study tested the null hypothesis that there are no differences between the preferences of hand surgeons and those patients with carpal tunnel syndrome (CTS) facing decisions about management of CTS (ie, the preferred content of a decision aid).

METHODS

One hundred three hand surgeons of the Science of Variation Group and 79 patients with CTS completed a survey about their priorities and preferences in decision making regarding the management of CTS. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid.

RESULTS

Important areas on which patient and hand surgeon interests differed included a preference for nonpainful, nonoperative treatment and confirmation of the diagnosis with electrodiagnostic testing. For patients, the main disadvantage of nonoperative treatment was that it was likely to be only palliative and temporary. Patients preferred, on average, to take the lead in decision making, whereas physicians preferred shared decision making. Patients and physicians agreed on the value of support from family and other physicians in the decision-making process.

CONCLUSIONS

There were some differences between patient and surgeon priorities and preferences regarding decision making for CTS, particularly the risks and benefits of diagnostic and therapeutic procedures.

CLINICAL RELEVANCE

Information that helps inform patients of their options based on current best evidence might help patients understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.

The BGN and ACAN genes and carpal tunnel syndrome

The causes of idiopathic carpal tunnel syndrome (CTS) remain unknown and the involvement of the tendons within the carpal tunnel structure in the aetiology of CTS cannot be excluded. Variants within the COL5A1 gene, an important regulator of fibril assembly in tendons, have previously been associated with modulating the risk of CTS. Furthermore, proteoglycans are also important structural components of tendons and variants within the aggrecan gene are associated with musculoskeletal soft tissue injuries. The aim of this study was to determine whether ACAN and BGN variants are associated with CTS. Self-reported Coloured participants (n=99), with a history of CTS release surgery (CTS), and 136 control participants, with no history of CTS symptoms (CON), were genotyped for ACAN rs1516797(G/T) and BGN rs1126499(C/T) variants. The BGN CC genotype was significantly over-represented (p=0.0498; OR=0.545, 95% CI=0.30-0.99) in the CON group (71.8%) versus the CTS (58.1%) group. When the previously reported associated COL5A1 genotypes were included in the analysis, COL5A1 and BGN gene-gene interactions were also shown to significantly modulate the risk of CTS in females. In conclusion this is the first study to report that variants within the BGN gene, independently and by interacting with COL5A1 variants, are associated with CTS. Further studies are required to replicate these findings.

Carpal tunnel syndrome - Part I (anatomy, physiology, etiology and diagnosis)

Carpal tunnel syndrome (CTS) is defined by compression of the median nerve in the wrist. It is the commonest of the compressive syndromes and its most frequent cause is idiopathic. Even though spontaneous regression is possible, the general rule is that the symptoms will worsen. The diagnosis is primarily clinical, from the symptoms and provocative tests. Electroneuromyographic examination may be recommended before the operation or in cases of occupational illnesses.

Systematic review and meta-analysis on the work-related cause of de Quervain tenosynovitis: a critical appraisal of its recognition as an occupational disease

BACKGROUND

The authors systematically reviewed all of the etiopathologic factors discussed in the literature to verify the classification of de Quervain tenosynovitis on the list of occupational diseases.

METHODS

The authors searched Ovid MEDLINE, EMBASE, and the Cochrane Library for articles discussing the cause of de Quervain tenosynovitis. The literature was classified by the level of evidence presented, the etiopathologic hypothesis discussed, the authors' conclusion about the role of the etiopathologic hypothesis, and the first author's professional background. The quality of reporting of the observational studies was evaluated by an extended Strengthening the Reporting of Observational Studies in Epidemiology statement checklist. A meta-analysis of all controlled cohort studies was performed. The Bradford Hill criteria were used to evaluate a causal relationship between de Quervain tenosynovitis and occupational risk factors.

RESULTS

A total of 179 references were found, and 80 articles were included. On average, only 35 percent (median, 35 percent; range, 16 to 60 percent) of all items on the extended Strengthening the Reporting of Observational Studies in Epidemiology checklist were addressed per article. The meta-analysis to evaluate the strength of the association between de Quervain tenosynovitis and (1) repetitive, (2) forceful, or (3) ergonomically stressful manual work suggested an odds ratio of 2.89 (95 percent CI, 1.4 to 5.97; p = 0.004). No evidence was found to support the Bradford Hill criteria for a causal relationship between de Quervain tenosynovitis and occupational risk factors.

CONCLUSION

No sufficient scientific evidence was provided to confirm a causal relationship between de Quervain tenosynovitis and occupational risk factors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Contralateral electrodiagnosis in patients with abnormal median distal sensory latency

BACKGROUND

We hypothesized that electrodiagnostic evidence of carpal tunnel syndrome (CTS) on the contralateral, less-severe side correlates with disease severity.

METHODS

We retrospectively reviewed 285 adults that had bilateral electrodiagnostic testing and a median distal sensory latency (DSL) greater than 3.6 ms on at least one side. Variables associated with abnormal contralateral median DSL were analyzed in bivariable and multivariable analysis.

RESULTS

Patients with a nonrecordable median DSL on the worst side were significantly more likely to have electrodiagnostic evidence of contralateral CTS compared to patients with a prolonged DSL on the worst side (90 versus 65 %, respectively; p < 0.001). Bilateral symptoms were reported by 75 % of patients. The best logistic regression model for electrodiagnostic evidence of contralateral CTS included nonrecordable median DSL of the worst side and polyneuropathy (p < 0.001 and p = 0.14, respectively).

CONCLUSIONS

The finding that disease severity relates to the probability of contralateral abnormalities is consistent with the concept that CTS is typically bilateral. Patients with CTS on one side should be advised of the likelihood that it can be present or may develop on the other side.

Pilot randomised controlled trial comparing C-Trac splints with Beta Wrist Braces for the management of carpal tunnel syndrome

Introduction

The C-Trac splint has been designed to mechanically stretch the transverse carpal ligament and is advertised as an alternative to surgical Carpal Tunnel Decompression. The purpose of the study is to compare the effectiveness of the C-Trac splint with standard splinting in mild to moderate idiopathic carpal tunnel syndrome.

Methods

This is a pilot parallel randomised controlled trial. Forty-nine patients with clinically and neurophysiologically proven carpal tunnel syndrome were randomised into the two treatment groups, C-Trac and Beta Wrist Brace, and reassessed clinically for one year.

Results

Patients were generally satisfied with both splints, but two out of the 24 C-Trac patients developed problematic side effects possibly due to using the splint: De Quervains tenosynovitis and basal joint arthritic pain. There was no clinically relevant or statistically significant difference in the success and failure rates of the two splints by eight weeks, six months or at one year. Three of the 25 C-Trac splints (costing £130 each) used during the one-year study required replacement, compared with eight of the Beta Wrist Braces (costing approximately £10 each).

Conclusions

These results suggest that C-Trac splint is not dissimilar in efficacy to a resting Beta Wrist Brace. The reported side effects raise questions as to the wisdom of its unregulated use.

Lamb boning -- an occupational cause of carpal tunnel syndrome?

Whether an occupation can cause carpal tunnel syndrome requiring carpal tunnel decompression (CTD) is contentious. We compared the demographics and incidence rates in lamb-freezing workers with the general population who had CTD. In the general population there were 1002 (63%) females and 583 (37%) males, mean age 48 years, and the rate of CTD was 1.36/1000 per annum. In lamb-freezing workers there were 225 males (mean age 38.4 years) and 60 females (mean age 44.6 years); most workers required CTD in their first three seasons. Compared with the general population, the incidence rate ratios in all freezing workers was 16.8; boners, 51.6; meat packers, 22.8; and slaughtermen, 5.4. All groups had a greater rate of CTD than the general population. This study suggests that carpal tunnel syndrome can be directly caused by an occupation.

Organic solvents as risk factor for autoimmune diseases: a systematic review and meta-analysis

BACKGROUND

Genetic and epigenetic factors interacting with the environment over time are the main causes of complex diseases such as autoimmune diseases (ADs). Among the environmental factors are organic solvents (OSs), which are chemical compounds used routinely in commercial industries. Since controversy exists over whether ADs are caused by OSs, a systematic review and meta-analysis were performed to assess the association between OSs and ADs.

METHODS AND FINDINGS

The systematic search was done in the PubMed, SCOPUS, SciELO and LILACS databases up to February 2012. Any type of study that used accepted classification criteria for ADs and had information about exposure to OSs was selected. Out of a total of 103 articles retrieved, 33 were finally included in the meta-analysis. The final odds ratios (ORs) and 95% confidence intervals (CIs) were obtained by the random effect model. A sensitivity analysis confirmed results were not sensitive to restrictions on the data included. Publication bias was trivial. Exposure to OSs was associated to systemic sclerosis, primary systemic vasculitis and multiple sclerosis individually and also to all the ADs evaluated and taken together as a single trait (OR: 1.54; 95% CI: 1.25-1.92; p-value<0.001).

CONCLUSION

Exposure to OSs is a risk factor for developing ADs. As a corollary, individuals with non-modifiable risk factors (i.e., familial autoimmunity or carrying genetic factors) should avoid any exposure to OSs in order to avoid increasing their risk of ADs.

A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration

BACKGROUND

We systematically reviewed etiological factors of Kienböck's disease (osteonecrosis of the lunate) discussed in the literature in order to examine the justification for including Kienböck's disease (KD) in the European Listing of Occupational Diseases.

METHODS

We searched the Ovid/Medline and the Cochrane Library for articles discussing the etiology of osteonecrosis of the lunate published since the first description of KD in 1910 and up until July 2012 in English, French or German. Literature was classified by the level of evidence presented, the etiopathological hypothesis discussed, and the author's conclusion about the role of the etiopathological hypothesis. The causal relationship between KD and hand-arm vibration was elucidated by the Bradford Hill criteria.

RESULTS

A total of 220 references was found. Of the included 152 articles, 140 (92%) reached the evidence level IV (case series). The four most frequently discussed factors were negative ulnar variance (n=72; 47%), primary arterial ischemia of the lunate (n=63; 41%), trauma (n=63; 41%) and hand-arm vibration (n=53; 35%). The quality of the cohort studies on hand-arm vibration did not permit a meta-analysis to evaluate the strength of an association to KD. Evidence for the lack of consistency, plausibility and coherence of the 4 most frequently discussed etiopathologies was found. No evidence was found to support any of the nine Bradford Hill criteria for a causal relationship between KD and hand-arm vibration.

CONCLUSIONS

A systematic review of 220 articles on the etiopathology of KD and the application of the Bradford Hill criteria does not provide sufficient scientific evidence to confirm or refute a causal relationship between KD and hand-arm vibration. This currently suggests that, KD does not comply with the criteria of the International Labour Organization determining occupational diseases. However, research with a higher level of evidence is required to further determine if hand-arm vibration is a risk factor for KD.