Carpal tunnel syndrome: complex issues with a "simple" condition

Causal relationship between rheumatoid arthritis and carpal tunnel syndrome: a bidirectional two-sample Mendelian randomization study

BACKGROUND

Although there is considerable evidence of a robust correlation between rheumatoid arthritis (RA) and carpal tunnel syndrome (CTS) in previous research, the causal link between the two remains a topic of controversy.

METHODS

We conducted a two-sample Mendelian randomization (MR) study to explore the causal impact of RA on CTS. We obtained aggregate data from genome-wide association studies (GWAS) of CTS (ebi database and GEO database) and RA (FinnGen database). This study employed five MR analysis methods, with a focus on the inverse variance-weighted (IVW) method. Sensitivity analyses were conducted to ensure the robustness of the results of this study. Additionally, we performed reverse MR analysis.

RESULTS

We selected 84 and 78 single nucleotide polymorphisms (SNPs) significantly associated with RA from two databases as instrumental variables (IVs), respectively. Our results showed that RA patients have a higher risk of getting CTS regardless of whether the ebi database (IVW, OR = 1.045, 95% CI: 1.016-1.075, P = 0.002) or the GEO database (IVW, OR = 1.001, 95% CI: 1.001-1.002, P = 0.001) is selected for CTS data. However, the MR analysis showed no causal link between CTS and the increased risk of RA (ebi: IVW, OR = 1.084, 95% CI: 0.918-1.279, P = 0.341; GEO: IVW, OR = 1.968, 95% CI: 0.011-360.791, P = 0.799).

CONCLUSION

The analysis revealed that RA can increase the risk of CTS, but did not support the causal relationship that CTS can increase the risk of RA.

Carpal Tunnel Syndrome in Elite Female Tug-of-War Athletes: Prevalence and Risk Factor Analysis

Background: Tug-of-War (TOW) games involve repetitive hand movements and vigorous force, raising the risk of peripheral neuropathy in the upper extremities. The prevalence of carpal tunnel syndrome (CTS) in TOW athletes remains unclear. We hypothesize that elite female TOW athletes have a higher prevalence of CTS than the general population. Methods: Twenty-nine female TOW athletes were recruited from a national team and participated in the study. CTS was clinically diagnosed by history taking and physical examination. Nerve conduction studies (NCS) were additionally performed to confirm CTS. Results: Twelve athletes were clinically diagnosed with CTS; however, only nine were confirmed by NCS. Ten athletes were diagnosed with subclinical CTS by NCS, while seven were classified as truly-non-CTS by both clinical assessment and NCS. The prevalence of CTS and subclinical CTS among the athletes was found to be 33.3% and 37.0%, respectively, significantly higher than 2.7% in the general population by electrodiagnosis. The body weight (p = 0.025) of the athletes with CTS and subclinical CTS was significantly different from those of the athletes without CTS. Conclusions: Our observations revealed a higher prevalence of CTS among elite female TOW athletes, with body weight being a risk factor. The forceful grasping and pulling of the rope may contribute to the development of CTS.

Registry cost description of carpal tunnel release in Finland in 2011-2015

OBJECTIVES

In this study, we evaluated the amount of public funds spent on the operative treatment of carpal tunnel syndrome (CTS) in Finland in 2011-2015.

DESIGN

A registry-based cost burden study.

SETTING

The data were collected in primary and secondary care in both private and public hospitals, covering the whole population of Finland.

PARTICIPANTS

We collected the total number of patients with new CTS diagnoses and the total number of patients undergoing surgery from the Care Register for Health Care, Finland's national register.

INTERVENTIONS

Open carpal tunnel release (OCTR).

OUTCOME MEASURES

We collected the costs of the OCTR procedure from diagnosis-related group prices. The Social Insurance Institution of Finland provided the total amount of euros reimbursed for sick leaves. We then combined the average amount of reimbursed sick leave with our estimated cost of the treatment chain to approximate the average cost per patient.

RESULTS

The average amount of public funds used for diagnosing and surgically treating new CTS in 2011-2015 in Finland, including reimbursements for sick leaves, was €2759 per patient in 2015 currency. The average direct procedure cost was €1020. We found no clear trend in total cost per patient, but the proportion of surgically treated patients rose from 63.14% to 73.09%. The total annual cost of these treatments was between €18 128 420 and €22 569 973.

CONCLUSIONS

The average amount of public funds used to surgically treat one patient with new CTS in 2011-2015 in Finland was €2759, making the total annual burden €20.7 million.

Endoscopic Carpal Tunnel Release With Monitored Anesthesia Care Versus Local Anesthesia: Analysis of Operative Times and Patient-Reported Outcomes

Purpose

Carpal tunnel syndrome is the most common peripheral nerve compressive neuropathy in clinical practice. Patients who fail nonsurgical management are indicated for carpal tunnel release (CTR), which can be performed open or endoscopically. Efforts have been made to utilize local anesthesia instead of monitored anesthesia care (MAC) for endoscopic release. This study seeks to compare perioperative surgical times and postoperative outcomes in patients undergoing endoscopic CTR with local anesthesia versus MAC.

Methods

This is a 6-year retrospective study of 1,036 patients undergoing isolated endoscopic CTR with MAC (n = 607) versus local (n = 429) anesthesia within an outpatient surgical center. A combination of chi-square and t tests was used to compare the patient characteristics, operative details, and outcomes.

Results

The local cohort demonstrated significantly shorter postoperative time to discharge (15.9 ± 9.8 vs 53.8 ± 11.0 minutes; P < .05), total time spent in surgical center (83.2 ± 18.7 vs 129.3 ± 20.7 minutes; P < .05), shorter total operating room time (26.7 ± 4.3 vs 29.0 ± 4.1 minutes; P < .05) and tourniquet time (12.4 ± 2.5 vs 13.1 ± 2.1 minutes; P < .05). Preoperative and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores were similar between the cohorts (P > .05); however, PROMIS pain interference improved to a higher degree between pre- and post-op in the local group (-1.5 vs -0.8; P = .02). Early and late surgical complications were similar between the groups (P > .05).

Conclusions

Patients within the MAC cohort demonstrated longer postoperative time to discharge and total time in the surgical center. The MAC cohort had longer operating room and tourniquet time, albeit not clinically significant. Surgical complications and PROMIS scores were similar between the two groups. Our findings suggest that local anesthesia is a safe and effective option for endoscopic CTR and may offer advantages in cost and convenience for patients.

Type of study/level of evidence

Retrospective cohort study/therapeutic III.

Risk of carpal tunnel syndrome among patients with osteoarthritis: a US population-based study

BACKGROUND

Carpal tunnel syndrome (CTS), an entrapment neuropathy caused by pressure of the median nerve, is a progressive condition that can lead to a decreased quality of life. Studies suggest an association between CTS and arthritis; however, previous studies examining osteoarthritis (OA) and CTS are limited in number, scope and study design. This study estimated the incidence and risk of CTS among patients with OA, both overall and by specific joints, in a large population-based cohort in the United States.

METHODS

Patients from the Optum claims database aged ≥ 45 years and diagnosed with OA between January 1, 2018, and December 31, 2022, were eligible for the OA cohort. The non-OA cohort included those without a diagnosis of OA at the index date and no history of OA for 12 months pre-index. Baseline characteristics were balanced using propensity score matching. The risk of CTS in the OA and non-OA cohort were evaluated using incidence rates and adjusted hazard ratios that were estimated using Cox regression.

RESULTS

After applying the inclusion/exclusion criteria, 3,610,240 of the 6,023,384 adults with a diagnosis of OA remained in the OA cohort. After propensity-score matching, each cohort included 1,033,439 individuals. The incidence rates for CTS per 1000 person-years were 7.35 (95% confidence interval [CI] 7.21-7.49) in the OA cohort and 1.44 (95% CI 1.38-1.50) in the non-OA cohort. The risk of developing CTS in patients with OA was ~ 4 times that of patients without (hazard ratio = 3.80; 95% CI 3.54-4.07). This increased risk was found across all OA joint types, with OA of the hand/wrist having the highest risk for CTS. Additionally, multiple OA joints presented a higher risk compared with a single affected joint.

CONCLUSIONS

OA increases the risk of CTS, but this is not limited to patients with hand/wrist OA, suggesting a systemic impact of OA on CTS. While the risk appears highest for patients with hand/wrist OA, patients with more distant affected joints like knee or hip also have an increased risk of CTS.

A randomized clinical trial on the changing of median nerve cross-sectional area and pain after extracorporeal shock wave and low-level laser therapy added to conventional physical therapy in patients with mild-to-moderate carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common mononeuropathy in the upper limb. It remains uncertain whether adding extracorporeal shockwave therapy (ESWT) or low-level laser therapy (LLLT) to conventional treatment benefits CTS patients.

PURPOSE

This study aimed to compare the effectiveness of ESWT and LLLT in conjunction with conventional treatments (including carpal mobilization, transcutaneous electrical nerve stimulation, and ultrasound) on the cross-sectional area (CSA) of the median nerve and pain in mild-to-moderate CTS patients.

STUDY DESIGN

This was a single-blinded randomized clinical trial with registration number IRCT20220504054734N1.

METHODS

Thirty-six patients were randomly assigned using block balanced randomization to receive either four sessions of ESWT or 10 sessions of LLLT in addition to 10 sessions of conventional treatments over 2 weeks. Patients received numbered closed envelopes indicating their treatment group. CSA (primary) and pain (secondary) in 18 patients who completed the treatment were assessed at baseline and after 2 weeks by a blinded assessor. Paired and independent sample t-tests were used for analyses due to the normal distribution of data was checked by Kolmogorov-Smirnoff. Cohen's d effect size was used to assess the intervention's magnitude.

RESULTS

Both ESWT and LLLT groups showed significant improvements in CSA (p = 0.002) and pain (p < 0.001) from baseline to posttreatment. CSA improvement was moderate for ESWT (mean difference: 1.2, 95% CI 0.51-1.9) and mild for LLLT (mean difference: 0.76, 95% CI 0.4-1.14). Conversely, pain improvement was substantial in both groups (ESWT: mean difference 4.4, 95% CI 3.6-5.3; LLLT: mean difference 4.4, 95% CI 3.7-5.2). No substantial differences between ESWT and LLLT were observed, highlighting their comparable efficacy.

CONCLUSION

The addition of either LLLT or ESWT to conventional treatment effectively reduced pain and median nerve CSA in mild-to-moderate CTS. The absence of significant differences between ESWT and LLLT indicates their comparable efficacy in pain relief and CSA reduction.

Local corticosteroid injection versus physical therapy for the treatment of carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials

The comparative effect of commonly used conservative treatments for carpal tunnel syndrome remained controversial. The purpose of this study was to compare the clinical effect of local corticosteroid injection and physical therapy for the treatment of carpal tunnel syndrome. A systematic literature search of PubMed, EMBASE, and Cochrane library was conducted to identify relevant randomized clinical trials published before 21st Mar 2023. Two independent reviewers assayed quality of included studies using the Cochrane collaboration risk of bias tool. Relevant data were extracted and pooled analyses were conducted. Outcome measurements included Boston Carpal Tunnel Syndrome Questionnaire, visual analogue scale and some electrophysiology tests, while the former two were set as the primary outcomes. Subgroup analysis and sensitive analysis were performed and publication bias was evaluated. Heterogeneity among the included studies was examined using the I2 statistic. After selection, 12 studies were identified eligibility for inclusion. Only one study was found to have a high risk of bias. Pooled data of primary outcomes did not show any differences between treatments, and subgroup analysis supported the results. However, patients treated with local corticosteroid injection showed better improvement in distal motor latency (p = 0.002) and compound muscle action potential (p = 0.04). Some studies failed to pass the sensitive analysis, indicating the related analysis might be not so stable. A slight publication bias was observed in subgroup analysis of function scales, among three publication bias test. In conclusion, compared to physical therapy, local corticosteroid injection might have better treatment effects on carpal tunnel syndrome.

Factors Associated with Change in Diagnosis of Carpal Tunnel Syndrome after Electrodiagnostic Studies

Background: Hand surgeons sometimes place more weight on clinical findings and may not always consider the results of electrodiagnostic studies (EDX) in the diagnosis of carpal tunnel syndrome (CTS). The aim of this study is to determine factors associated with a change in diagnosis of CTS after EDX. Methods: This is a retrospective study of all patients with an initial clinical diagnosis of CTS who underwent EDX at our hospital. We identified patients whose diagnosis changed from CTS to non-CTS after EDX and used univariate and multivariate analysis to determine if age, sex, hand dominance, unilateral symptoms, history of diabetes mellitus, rheumatoid arthritis, haemodialysis, cerebral lesion, cervical lesion, mental disorder, initial diagnosis by a non-hand surgeon, the number of examined items in CTS-6 and a CTS-negative EDX result were associated with a change in diagnosis after EDX. Results: A total of 479 hands with a clinical diagnosis of CTS underwent EDX. The diagnosis was changed to non-CTS in 61 hands (13%) after EDX. Univariate analysis demonstrated that unilateral symptoms, cervical lesion, mental disorder, initial diagnosis by a non-hand surgeon, the number of examined items and a CTS-negative EDX result were significantly associated with a change in diagnosis. In the multivariate analysis, only the number of examined items was significantly associated with a change in diagnosis. Conclusions: EDX results were particularly valued in hands where the initial diagnosis was uncertain for CTS. In hands with an initial diagnosis of CTS, the performance of sufficient history-taking and physical examination was more valued at the final diagnosis than EDX results or other aspects of the patient's background. The process of confirming a clear initial clinical diagnosis of CTS using EDX may be of little value for decision-making at the final diagnosis. Level of Evidence: Level III (Therapeutic).

Carpal tunnel syndrome: updated evidence and new questions

Carpal tunnel syndrome is the most common entrapment neuropathy, affecting quality of life for many people. Although it is a well recognised condition, new insights into epidemiology, diagnosis, and treatment have emerged in the past 6 years. The availability of disease-modifying treatments for rare systemic disorders associated with carpal tunnel syndrome (eg, amyloidosis) should alert clinicians to these diagnostic possibilities. Besides clinical evaluation and electrophysiology, the role of ultrasonography as a diagnostic tool has been confirmed and new ultrasound techniques have been applied, the clinical use and feasibility of which require further investigation. Surgical and non-surgical interventions are beneficial for the treatment of carpal tunnel syndrome and several treatment options are now available, giving clinicians the possibility to choose the best approach for every patient. New diagnostic and therapeutic techniques require further validation.

Manual Therapy and Related Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

Objective: Systematic review and meta-analysis to assess the efficacy of Manual therapy and related interventions in the treatment of carpal tunnel syndrome (CTS) based on Boston carpal tunnel questionnaire. Design: Systematic review and meta-analysis. Subjects: Carpal tunnel syndrome. Interventions: Manual therapy and related interventions versus other therapies or manual therapy and related interventions plus other therapies versus other therapies. Outcomes measures: Boston carpal tunnel questionnaire. Results: A total of 6 studies were included, including 211 cases in the manual therapy group and 211 cases in the control group. The quality of the included articles was high, and the results of meta-analysis showed that manual therapy and related interventions were superior in terms of improving the Boston carpal tunnel questionnaire Symptom Severity score in patients with CTS (standardised mean difference [SMD] -1.13, 95% CI -1.40 to -0.87), were superior to control groups in terms of improving the Boston carpal tunnel questionnaire functional capacity scale in patients with CTS (SMD -1.01,95% CI -1.24 to -0.77). Conclusion: The results of this meta-analysis suggested that manual therapy and related interventions were better than control groups in treating CTS. Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS. Registration: The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; No. CRD 42020201389). Contribution of the Article: Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS.

Is the left/right judgment task performance altered in unilateral carpal tunnel syndrome: And associated with symptom severity?

BACKGROUND

Left/right judgment task performance (LRJT) is impaired in severe neuropathic pain conditions. However, comparison of LRJT performance in patients with carpal tunnel syndrome (CTS) with a control group with similar cognitive functions has not been investigated.

OBJECTIVE

The aim of the study was to compare the LRJT performance of CTS patients with healthy controls and the unaffected side.

METHODS

Seventy-five CTS patients with dominant, right-hand involvement and 75 control subjects were included in the study. The Recognize® tablet application was used for LRJT performance. Tactile acuity (Two-point discrimination) and handgrip strength; pain severity (Visual Analog Scale) and neuropathic component of pain (Pain Detect Questionnaire); symptom severity and functional impact of CTS (Boston CTS Assessment Test) were evaluated. Mixed-design ANOVAs and correlation analyses were used for data analysis.

DESIGN

Cross-sectional study.

RESULTS

Analysis of variance showed that there was no significant effect of side (affected versus unaffected) or group (CTS versus control group) on recognition accuracy or time. Significant group*site interactions were found for the two-point discrimination F (1,148) = 6.388, p = 0.013; and for handgrip strength F (1,148) = 17.552, p < 0.01. A statistically significant negative correlation was found between recognition accuracy and symptom duration and a significant positive correlation was found between recognition accuracy and handgrip strength in CTS patients (r = -0.267, p = 0.020; r = 0.290, p = 0.012).

CONCLUSION

CTS patients recognize the affected side as accurately and quickly as the unaffected side and control group. Further research is needed to clarify the relationship between LRJT performance in the severely affected CTS group.

GOV REGISTRATION NUMBER

NCT04967144 CLINICALTRIALS.

GOV REGISTRATION DATE

19 July 2021.

Musculoskeletal complications in patients with diabetes mellitus

Musculoskeletal conditions are common in patients with diabetes. Several musculoskeletal disorders are viewed as chronic complications of diabetes because epidemiological studies have revealed high correlations between such complications and diabetes, but the pathophysiological links with diabetes remains unclear. Genetic predispositions, shared risk factors, microvascular impairments, progressive accumulation of advanced glycation end-products, and diabetic neuropathy may underlie the development of musculoskeletal disorders. Musculoskeletal complications of diabetics have received less attention than life-threatening microvascular or macrovascular complications. Here, we review several diabetic musculoskeletal complications with a focus on the clinical importance of early recognition and management, which would improve quality of life and physical function.

A clinical study of thread carpal tunnel release with a newly developed thread: A retrospective pilot study

INTRODUCTION

Previous studies have shown that, thread carpal tunnel release (TCTR), an ultrasound-guided transverse carpal ligament (TCL) transection procedure through needle and thread, to be a safe and effective technique for carpal tunnel release, compared to an open and endoscopic technique. We developed a newly improved thread (Smartwire-01, 0.27mm in diameter, Korea). This pilot study was performed to propose the effectiveness of TCTR with Smartwire-01 compared to the commercial thread in clinical settings.

METHODS

A total of 22 TCTR procedures have been performed on 19 patients by one physiatrist during a 42-month period. The diagnosis of carpal tunnel syndrome was based on standard clinical criteria including electromyography (EMG). Patients were divided into two groups, one dissected with commercial thread and the other with Smartwire-01. The technique was standardized by keeping the entry point at the middle of the palm and the exit point at just medial to the palmaris longus tendon. The Numeric Rating Scale and Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) were used to assess monthly outcomes for 6 months following the procedure. The Wilcoxon signed rank test and the Mann-Whitney-U test were performed to analyze the above variables in the two groups.

RESULTS

There was no definite evidence that the two groups have significant differences for any of the surveyed variables. The TCTR procedure with our newly developed thread also had significant improvements for all variables, showing its effectiveness in both pain and functional ability. The NRS and BCTQ severity and functional scales showed significant decreases just after the dissection and progressive improvement during each monthly follow-up of our study until the last assessment at 6 months.

CONCLUSION

The study suggests that, our newly developed thread is as safe and effective as the commercial thread in TCTR, we therefore recommend a randomize controlled trial with above methodology.

Using deep learning for ultrasound images to diagnose carpal tunnel syndrome with high accuracy

Recently, deep learning (DL) algorithms have been adapted for the diagnosis of medical images. The purpose of this study was to detect image features using DL without measuring median nerve cross-sectional area (CSA) in ultrasonography (US) images of carpal tunnel syndrome (CTS) and calculate the diagnostic accuracy from the confusion matrix obtained. US images of 50 hands without CTS and 50 hands diagnosed with CTS were used in this study. The short-axis image of the median nerve was visualized, and 5000 images of both groups were prepared. Forty hands in each group were used as training data for the DL algorithm, while the remainder were used as test data. Transfer learning was performed using three pre-trained models. The confusion matrix and receiver operating characteristic curves were used to evaluate diagnostic accuracy. Furthermore, regions where DL was determined to be important were visualized. The highest score had an accuracy of 0.96, precision of 0.99 and recall of 0.94. Visualization of the important features revealed that the DL models focused on the epineurium of the median nerve and the surrounding soft tissue. The proposed technique enables the accurate prediction of CTS without measurement of the CSA.

Carpal tunnel syndrome associated with chronic bursitis: A case report

This current report presents a rare case of carpal tunnel syndrome with chronic bursitis that was treated successfully by open surgery. A 53-year-old female patient that had begun to experience swelling, pain and limited flexion activity of the left wrist 1 year previously presented because of a deterioration in her condition and numbness of the thumb, index finger and middle finger in the previous 2 months without any treatment. The diagnosis of bursitis should be based on clinical symptoms and signs, combined with colour ultrasonography, magnetic resonance imaging, arthroscopy and arthrography. Bursitis should be differentiated from arthritis, tendonitis, fracture and neoplasm, but complete exclusion depends on the postoperative pathological results. In this current case, the histopathological findings were consistent with bursitis without malignancy. After surgery, the patient was instructed to perform rehabilitation exercises for the wrist joint. These exercises included passive activity 3 days after surgery and active activity 1 week after surgery. There was also regular follow-up every 3 months. The patient recovered well and reported that the pain and numbness that she described preoperatively had been resolved.

Genome-wide association and Mendelian randomization study of blood copper levels and 213 deep phenotypes in humans

Metal elements are present in the human body, and their levels in the blood have important impacts on health. In this study, 2488 Chinese individuals were included in a genome-wide association study of 21 serum metal levels, with approximately 179,000 East Asian individuals in a bidirectional two-sample Mendelian randomization (MR) analysis, and 628,000 Europeans in a two-sample MR analysis. We identified two single nucleotide polymorphisms (SNPs) rs35691438 and rs671 that were significantly associated with serum copper levels (SCLs). The bidirectional two-sample MR analysis in the East Asian population showed that gamma-glutamyl transpeptidase levels have a causal effect on SCLs. SCLs have causal effects on six outcomes, namely risks of esophageal varix, glaucoma, sleep apnea syndrome, and systemic lupus erythematosus, white blood cell count, and usage of drugs affecting bone structure and mineralization. The two-sample MR analyses in the European population showed causal effects of erythrocyte copper levels on risks of carpal tunnel syndrome and compression fracture. Our results provide original insights into the causal relationship between blood metal levels and multiple human phenotypes.

A genome-wide association study in a Chinese population identifies SNPs associated with serum copper levels. Mendelian randomization analysis reveals causal effects on multiple human phenotypes in East Asian and European populations.

Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes

BACKGROUND

Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute.

METHODS

A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups.

RESULTS

A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P < 0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001).

CONCLUSIONS

More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.

Safe Zones for Percutaneous Carpal Tunnel Release

Carpal tunnel release (CTR) is an effective procedure used in open, endoscopic, or ultrasound-guided methods. The complications are rare but potentially devasting. Most complications come from errors related to intraoperative technique, especially in the minimally invasive approach. An understanding of the "safe zones" is essential to perform percutaneous CTR safely. This article reviews the anatomy of safe zones and the ultrasound-guided CTR (UCTR) techniques in an attempt to prevent intraoperative complications. In strict accordance with the concepts of safe zones, UCTR is an effective and reliable procedure. Substantial experience for ultrasound-guided injection and surgery is required.

Diagnosis of carpal tunnel syndrome in non-diabetic patients with hemodialysis using ultrasound: Is it a useful adjunctive tool?

OBJECTIVE

(1) To examine the ultrasound (US) characteristics in patients with hemodialysis-related carpal tunnel syndrome (H-CTS) and (2) to evaluate the accuracy of a proposed US parameter-dynamic ratio of median nerve-to-hamate hook distance (RMHD) in diagnosis of H-CTS.

DESIGN

A case-control study.

SETTING

In a tertiary medical center and a secondary hospital from Nov. 2017 to Mar. 2021.

PARTICIPANTS

Consecutive non-diabetes patients under hemodialysis were recruited and divided into a hemodialysis without CTS (H-Control) group and an H-CTS group. Age-matched volunteers without diabetes or upper extremity disorders were enrolled as the Control group.

INTERVENTION

Ultrasound examinations by two operators blinded to the patient's clinical information.

MAIN OUTCOME MEASURES

US parameters including cross-sectional area of the median nerve at the carpal tunnel inlet (CSA-I) and outlet (CSA-O), the flattening ratio of the median nerve at the inlet (FR-I) and outlet (FR-O), and RMHD.

RESULTS

Handedness and arteriovenous fistula showed no associations with CSA-I/O and FR-I/O. Compared with Control group (n=69), the CSA-I was significantly larger in the H-Control group (n=63) and H-CTS group (n=76) (p<0.05). There were no significant differences in the FR-I/-O among the three groups. For the second aim, in the H-CTS group(n=38), there was a significantly lower RMHD compared with both the Control (n=20) and H-Control groups (n=30) (0.1%±2.2% versus 3.5±2.3% and 3.8±1.7%, p<0.05). An RMHD cutoff value of <2.7% yielded a specificity of 80.0%, a sensitivity of 94.7%, and an overall accuracy of 88.2% in the diagnosis of H-CTS.

CONCLUSIONS

Neither CSA-I/-O or FR-I/-O have a role in the diagnosis of H-CTS. RMHD might be a useful US parameter in the diagnosis of CTS in non-diabetic patients undergoing hemodialysis.

The association of sensory phenotype and concomitant mood, sleep and functional impairment with the outcome of carpal tunnel surgery

BACKGROUND

Up to 25% of people who have had carpal tunnel release surgery (CTR) fail to report improvement; however, evidence for prognostic indicators in this surgical cohort is limited. To identify candidate prognostic factors, this study investigated the association of quantitative sensory testing (QST) derived sensory phenotype and attendant impairment with patient-reported surgical outcome.

METHODS

With ethical approval and informed consent, this prospective observational longitudinal study recruited patients from two London hospitals. Multimodal phenotyping measures including quantitative sensory testing (QST), pain parameters, insomnia, pain-related worry, mood and function, were evaluated prior to; and at 3- and 6-months post-surgery. Pain in median nerve distribution with electrophysiologically confirmed conduction delay and DN4 score ≥ 4 was defined as neuropathic. Primary outcome was patient-rated change at 6 months, dichotomised as poor outcome; "worse" or "no change" and good outcome; "slightly better", "much better" or "completely cured".

RESULTS

Seventy-six patients participated. Prior to surgery, substantial heterogeneity in established categories of somatosensory function was observed with 21% of participants categorised as having a healthy sensory phenotype; 29% with thermal hyperalgesia; 32% mechanical hyperalgesia and 18% sensory loss. Seventy six percent of participants were classified as having neuropathic pain, 33% with high levels of pain related worry and 64% with clinical insomnia. Observed differences in pain, sleep impairment, psychological factors and function, between sensory phenotypic groups, was not significant. At 3- and 6-months post-surgery there was significant improvement in all phenotyping measures with a moderate to large effect size. Thermal and mechanical measures of somatosensation improved (p < 0.001), as did functional ability (p < 0.001). Symptom severity diminished (p < 0.001), as did pain-related worry (p < 0.001), anxiety (p = 0.02) and insomnia (p < 0.001). Patient-rated surgical outcome was good in 92% of the cohort, poor in 8%. Baseline sensory phenotype category was not associated with surgical outcome however pain-related worry, anxiety and functional interference were significantly associated with outcome (p ≤ 0.05).

CONCLUSION

In patients undergoing carpal tunnel surgery, pain-related worry, anxiety and pain functional interference are candidate prognostic outcome factors and require further elucidation.

Extracorporeal shock wave therapy versus local corticosteroid injection for the treatment of carpal tunnel syndrome: a meta-analysis

BACKGROUND

Many studies have demonstrated the effectiveness of extracorporeal shock wave therapy (ESWT) and local corticosteroid injection (LCI) for the treatment of carpal tunnel syndrome (CTS), and some studies showed that the effect of ESWT was superior to LCI. We performed this meta-analysis to compare the clinical effects across the two therapies.

METHODS

Relevant randomized controlled trials (RCTs) comparing ESWT and LCI for the treatment of CTS were searched in electronic database. The Cochrane risk bias tool was used for quality assessment. After data extraction and quality assessment of the included studies, a meta-analysis was performed using RevMan 5.3 software. Mean differences (MDs), odds ratios (ORs), and 95% confidence intervals (CIs) were analyzed. The protocol for this systematic review was registered on INPLASY (202080025) and is available in full on the inplasy.com ( https://doi.org/10.37766/inplasy2020.8.0025 ) RESULTS: A total of 5 RCT studies with 204 patients were included from the electronic database. The meta-analysis results showed that two therapies were not significantly different in terms of visual analog scale (VAS) score (P = 0.65), Boston Carpal Tunnel Questionnaire (BQ) score (P = 0.14), sensory distal latency (P = 0.66), and nerve conduction velocity (NCV) of the sensory nerve (P = 0.06). There were significant differences between the results of motor distal latency (P < 0.0001), compound muscle action potential (CMAP) amplitude (P < 0.00001), and sensory nerve action potential (SNAP) amplitude (P = 0.004).

CONCLUSIONS

In terms of pain relief and function improvement, the effects of ESWT and LCI are not significantly different. In terms of electrophysiological parameters, LCI has a stronger effect on shortening motor distal latency; ESWT is superior to LCI in improving action potential amplitude. ESWT is a noninvasive treatment with fewer complications and greater patient safety. In light of the heterogeneity and limitations, these conclusions require further research for definitive conclusions to be drawn.

Extracorporeal Shockwave Therapy in Pillar Pain after Carpal Tunnel Release: A Prospective Randomized Controlled Trial

Background

The aim of this study was to evaluate the effect of extracorporeal shockwave therapy (ESWT) on pillar pain after carpal tunnel release.

Materials and Methods

In this prospective randomized controlled trial, forty patients with pillar pain for at least 1 month after carpal tunnel release surgery were randomly assigned in two groups. ESWT group received four sessions of ESWT at weekly intervals, and patients in the control group received sham ESWT treatment at the same intervals, involved sound but no energy. At baseline, 1^st month, and 3^rd month, hand function (using Brief-Michigan Hand Outcome Questionnaire) and pain score were assessed and compared between groups.

Results

At baseline, pain score and hand function score were similar in both groups. After 1^st month, pain score in ESWT and control groups was 3.7 versus 4.7, respectively (P = 0.066), and hand function score was 60.7 versus 52.2, respectively (P = 0.032). After 3 months, pain score in ESWT group was significantly lower than the control group (1.6 versus 3.6, respectively, P < 0.0001), hand function score in ESWT group was significantly better than the control group (75.4 vs. 63.7, respectively, P < 0.0001). Trend of decrease in pain score between groups was significantly different, but trend of increase in hand function score was not significantly different.

Conclusion

After ESWT, hand function and pain score in patients with pillar pain improved faster compared to control patients. Hence, ESWT can be used as a safe and effective noninvasive technique in patients with pillar pain after carpal tunnel release.

The Effectiveness of Ultrasound-Guided Steroid Injection Combined with Miniscalpel-Needle Release in the Treatment of Carpal Tunnel Syndrome vs. Steroid Injection Alone: A Randomized Controlled Study

Objectives

Carpal tunnel syndrome (CTS) is one of the most common nerve entrapment syndromes, which has a serious impact on patients' work and life. The most effective conservative treatment is steroid injection but its long-term efficacy is still not satisfactory. The aim of this study was to evaluate the effectiveness of steroid injection combined with miniscalpel-needle (MSN) release for treatment of CTS under ultrasound guidance versus steroid injection alone. We hypothesized that combined therapy could be more beneficial.

Methods

Fifty-one patients with CTS were randomly allocated into two groups, namely, steroid injection combined with MSN release group and steroid injection group. The therapeutic effectiveness was evaluated using Boston Carpal Tunnel Questionnaire (BCTQ), cross-sectional area (CSA) of the median nerve, and four electrophysiological parameters, including distal motor latency (DML), compound muscle action potential (CMAP), sensory nerve action potential (SNAP), and sensory nerve conduction velocity (SNCV) at baseline, 4 and 12 weeks after treatment.

Results

Compared with baseline, all the parameters in both groups showed statistically significant improvement at week 4 and week 12 follow-up, respectively (P<0.05). When compared with steroid injection group, the outcomes including BCTQ, DML, CMAP, SNCV, and CSA of the median nerve were significantly better in steroid injection combined with MSN release group at week 12 after treatment (P<0.05).

Conclusions

The effectiveness of steroid injection combined with MSN release for CTS is superior to that of steroid injection alone, which may have important implications for future clinical practice. This Chinese clinical trial is registered with ChiCTR1800014530.

Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome including mid-term efficacy: a prospective randomized controlled trial

BACKGROUND

Recent studies have reported that radial extracorporeal shock wave therapy (rESWT) reduces pain and improves function in patients with mild to moderately severe carpal tunnel syndrome (CTS) compared to a placebo. However, most of those studies used multi-session rESWT combined with wrist support and evaluation of efficacy was limited to a maximum of 14 weeks.

METHODS

The prospective randomized controlled trial compared efficacy in relieving pain and improving clinical function between single-dose rESWT and local corticosteroid injection (LCsI) over the mid-term (24 weeks). Twenty-five patients with mild to moderately severe CTS were randomized to receive either single-dose rESWT (n = 13) or LCsI (n = 12). Primary outcomes were evaluated using the Boston self-assessment questionnaire (BQ), while secondary outcomes used the Visual analogue scale (VAS) and electrodiagnostic parameters. Evaluations at baseline and at 1, 4, 12 and 24 weeks after treatment were performed.

RESULTS

There was significantly greater improvement in symptom severity scores, functional scores and Boston questionnaire scores at weeks 12 to 24 in the rESWT group compared to the LCsI group. When compared to the baseline, there was significant reduction of VAS and functional score in the rESWT group at weeks 12 and 24. The LCsI group had no statistically significant differences in VAS reduction and functional score of the same period.

CONCLUSIONS

Treatment of CTS using single-dose rESWT has a carry-over effect lasting up to 24 weeks suggesting that single-dose rESWT is appropriate for treatment of mild to moderate CTS and provides longer-lasting benefits than LCsI.

TRIAL REGISTRATION

( TCTR20150709001 ). Registered 9 July 2015.

Carpal tunnel syndrome: clinical features, diagnosis, and management

Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome worldwide. The clinical symptoms and physical examination findings in patients with this syndrome are recognised widely and various treatments exist, including non-surgical and surgical options. Despite these advantages, there is a paucity of evidence about the best approaches for assessment of carpal tunnel syndrome and to guide treatment decisions. More objective methods for assessment, including electrodiagnostic testing and nerve imaging, provide additional information about the extent of axonal involvement and structural change, but their exact benefit to patients is unknown. Although the best means of integrating clinical, functional, and anatomical information for selecting treatment choices has not yet been identified, patients can be diagnosed quickly and respond well to treatment. The high prevalence of carpal tunnel syndrome, its effects on quality of life, and the cost that disease burden generates to health systems make it important to identify the research priorities that will be resolved in clinical trials.

The effects of active release technique on carpal tunnel patients: A pilot study

OBJECTIVE

To examine changes in electromyography (EMG) and a valid self-administered outcome measure after applying active release technique to carpal tunnel syndrome (CTS) patients.

METHODS

Five subjects (mean age 48.2 SD +/- 16.7) with CTS were included in the trial. Subjects completed the Boston Questionnaire (BQ) and an EMG examination before the first treatment. Participants were treated with Active Release technique using a protocol intended to affect the median nerve 3 times a week for 2 weeks. The BQ was re-administered following the final treatment. The mean scores for the initial and final BQ were compared using a paired samples t-test. An analysis of variance compared the mean contraction amplitudes for EMG parameters before and after the first treatment.

RESULTS

There was significant improvement (p < 0.05) in the mean symptom severity and functional status scores of the BQ following the intervention. There were no significant differences found in the EMG analyses.

CONCLUSION

The preliminary data from this clinical pilot trial suggest that active release technique may be an effective conservative management strategy for CTS patients. These results support the need for further clinical trials with larger samples.

Disparity between popular (Internet) and scientific illness concepts of carpal tunnel syndrome causation

PURPOSE

To determine whether there are notable disparities between popular (Internet) and scientific (Index Medicus) theories of carpal tunnel syndrome (CTS) causation.

METHODS

Reports from 3 sources were evaluated with regard to support for etiological theories of CTS: 1) patient-oriented information on CTS from the Internet, 2) recent physician-oriented information on CTS from medical journals indexed on Index Medicus, and 3) articles addressing the etiology of CTS from the 1997 National Institute for Occupational Safety and Health report. Multiple logistic regression analyses evaluated differences in etiological theories from the 3 sources.

RESULTS

Internet sites implicated vitamin B(6) deficiency, tenosynovitis, and typing or computer use as causes for idiopathic CTS considerably more often and genetic predisposition considerably less often than recent Index Medicus scientific reports and reports reviewed by the National Institute for Occupational Safety and Health.

CONCLUSIONS

There are notable disparities between popular (Internet) and scientific (Index Medicus) theories of CTS causation.

The Relationship Between Electrodiagnostic Findings and Patient Symptoms and Function in Carpal Tunnel Syndrome

OBJECTIVE

To examine whether, in patients with carpal tunnel syndrome (CTS), electrodiagnostic study findings were associated with patient symptom severity and functional limitations after controlling for potentially confounding variables including depression, somatization, and pain-related catastrophizing.

DESIGN

Cross-sectional design including data from 2 ongoing CTS studies.

SETTING

Patients enrolled from hospitals and clinics in Washington State between October 2002 and February 2006.

PARTICIPANTS

Adults with CTS (N=215) (based on symptoms and abnormal electrodiagnostic findings) were analyzed. Exclusion criteria were any mass, tumor, severe trauma, or deformity in the hand or wrist, radiculopathy, polyneuropathy, pregnancy, lactation, or severe CTS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) functional status scale assessed the ability to perform 9 common hand-related tasks. The CTSAQ symptom severity scale included 11 items that assess pain, numbness, and weakness. Patients also rated their average hand and wrist pain in the last month.

RESULTS

With and without controlling for patient characteristics, including age, sex, body mass index, symptom duration, depression, somatization, and pain-related catastrophizing, there were no statistically significant relationships between the electrodiagnostic findings and patient functional status and symptom severity.

CONCLUSIONS

Electrodiagnostic findings and patient CTS-related symptoms and function appear to be independent measures. Clinicians and researchers interested in CTS outcomes need to assess both.

Multicenter study on carpal tunnel syndrome and pregnancy incidence and natural course

OBJECTIVE

To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS and to assess the course of carpal tunnel syndrome after pregnancy.

METHODS

During 2000-2001, the Italian CTS study group in 7 Italian centers studied the occurrence of CTS in women during the last period of pregnancy. The group enrolled and followed-up (10-15 months) 63 women during and after pregnancy with multiple measurements of CTS. In addition to the physician-centered and neurophysiologic traditional evaluations, a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment was adopted.

RESULTS

CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Comparison of baseline and follow-up data showed a significant spontaneous improvement of patient-oriented and neurophysiologic measurements. Nevertheless, about half of women with CTS during pregnancy still complained of CTS symptoms one year after delivery.

CONCLUSIONS

Our observations confirmed the frequent occurrence of CTS in pregnancy. At follow-up we observed that most CTS cases improve spontaneously without treatment but only in half of women CTS symptoms disappeared one year after delivery.

Effect of Occupational Keyboard Typing on Magnetic Resonance Imaging of the Median Nerve in Subjects with and without Symptoms of Carpal Tunnel Syndrome

OBJECTIVE

To examine the effects of occupational keyboard typing on median nerve shape and T2 relaxation and on forearm muscle T2 in professional typists with and without symptoms of carpal tunnel syndrome.

DESIGN

Based on the Levine Carpal Tunnel Syndrome Symptom Severity scale (LCTSS), 12 female professional typist volunteers were divided into asymptomatic (LCTSS < 1.3, n = 5) and symptomatic (LCTSS > 1.3, n = 7) groups. Magnetic resonance images were acquired from wrist and forearms of all subjects before, immediately after, and 8 hrs after 3 hrs of typing. Forearm muscle T2 and median nerve T2 cross-sectional area and long/short axis ratio were evaluated by blinded observers.

RESULTS

There was no difference between groups in any measured variable before typing. Median nerve T2 increased and long/short axis ratio decreased in asymptomatic subjects after typing, but there were no significant changes in symptomatic subjects. T2 increased in finger flexor muscles after typing, but there was no difference in the pattern of muscle T2 changes between groups.

CONCLUSION

In magnetic resonance images of the median nerve at the carpal tunnel, swelling and T2 increases from baseline are a normal response to typing and may be less likely to occur in subjects with symptoms of carpal tunnel syndrome.

Compliance with electrodiagnostic guidelines for patients undergoing carpal tunnel release

OBJECTIVE

To describe how clinical practice in those who underwent carpal tunnel release (CTR) matched the American Association of Electrodiagnostic Medicine (AAEM) 1993 practice parameters for electrodiagnostic evaluation of carpal tunnel syndrome (CTS).

DESIGN

Cohort study using 1998-1999 Medicare billing data.

SETTING

Washington State.

PARTICIPANTS

State Medicare beneficiaries who underwent CTR in 1999 (N=1567) Interventions Not applicable.

MAIN OUTCOME MEASURES

Compliance with the AAEM practice parameters.

RESULTS

Of the 1567 [corrected] receiving surgery, 324 [corrected] (20.7%) did not have any electrodiagnostic testing before surgery. One hundred seventy-one (10.9%) had testing performed that did not lead to the diagnosis of CTS. One thousand seventy-two (68.4%) patients were diagnosed with CTS through electrodiagnostic testing; 155 (9.9%) had less than 2 sensory nerves studied, 114 (7.3%) had less than 2 motor nerves studied, and 65 (4.2%) of the studies met neither the standard (sensory nerve testing) nor guideline (motor nerve testing). In a multivariate analysis, neurologists were more likely than physiatrists not to meet the AAEM standards (adjusted relative risk [adj RR]=1.61; 95% confidence interval [CI], 1.13-2.31) and patients living in rural areas were more likely to have no or inadequate testing (adj RR=1.6; 95% CI, 1.3-1.9).

CONCLUSIONS

Over one third of Medicare patients undergoing CTR in Washington State in 1999 may have had an inappropriate electrodiagnostic workup before the surgery. Policymakers should consider mandating an appropriate electrodiagnostic test before approving CTR.

What can family physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of nonsurgical management

BACKGROUND

We undertook a literature review to produce evidence-based recommendations for nonsurgical family physician management of carpal tunnel syndrome (CTS).

METHODS

Study design was systematic review of randomized controlled trials (RCTs) on CTS treatment. Data sources were English publications from all relevant databases, hand searches, and guidelines. Outcomes measured were nonsurgical management options for CTS.

RESULTS

We assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using historical controls. A considerable percentage of CTS resolves spontaneously. There is strong evidence that local corticosteroid injections, and to a lesser extent oral corticosteroids, give short-term relief for CTS sufferers. There is limited evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic ultrasound may be effective in the short to medium term (up to 6 months). The evidence for nerve and tendon gliding exercises is even more tentative. The evidence does not support the use of nonsteroidal anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic treatment, or magnet treatment.

CONCLUSIONS

For those who are not able to get surgery or for those who do not want surgery, there are some conservative modalities that can be tried. These modalities include ones for which there is good evidence. It would be reasonable to try some of the techniques with less evidence if the better ones are not successful. Reconsideration of surgery must always be kept in mind to avoid permanent nerve damage.