A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment

Effects of Kinesio tape on individuals with carpal tunnel syndrome: a randomized controlled study

Objective

Carpal tunnel syndrome (CTS) is a common neuromuscular disorder with an incidence rate of 4.9%. Research on the impact of Kinesio taping (KT) on electroneurography in individuals with CTS is limited, highlighting a significant gap in the literature. This study aimed to evaluate the effects of KT on palm numbness, pain intensity, hand grip strength, and median nerve electroneuromyography in individuals with mild to moderate CTS.

Method

This was a randomized, controlled, parallel design study. Twenty-seven participants diagnosed with CTS through hospital outpatient clinics were randomly assigned to either the control or KT group. The outcome measurements included hand grip strength, the Boston Carpal Tunnel Questionnaire (BCTQ), and electroneurography, assessed at baseline and after 6 weeks of intervention. The statistical method used was non-parametric analysis, comparing differences with the median and interquartile range (IQR).

Results

Both the KT and control groups significantly improved the numbness grades, hand grip strength, and the BCTQ. The kinesio-taping group demonstrated an improvement in grip strength with a median increase of 2.21 kg (IQR: 0.65-3.79 kg), compared to the control group, which showed a median increase of only 0.70 kg (IQR: 0.22-1.45 kg). Statistical analysis revealed a significant difference between the two groups (p = 0.039), with an effect size of r = 0.33.

Conclusion

This study suggested that KT can be a supplementary treatment to relieve pain intensity, enhance hand grip strength, and improve sensory conduction velocity, motor latency, and motor amplitude.

Clinical Trial Registration

https://doi.org/10.1186/ISRCTN82192319, ISRCTNregistry (No. ISRCTN82192319).

Carpal tunnel syndrome related to rheumatic disease (Review)

Carpal tunnel syndrome (CTS) is the most commonly occurring type of entrapment neuropathy in the world. Several conditions may contribute to the development of CTS, such as obesity, repetitive wrist movements, pregnancy, genetic predisposition and rheumatoid arthritis (RA) inflammation. CTS is characterized by a wide range of pathophysiological factors, including increased pressure, mechanical trauma and ischemic damage to the median nerve that runs through the wrist tunnel. In the present narrative literature review, the way rheumatic diseases (RDs) contribute to CTS occurrence is investigated. The epidemiological, clinical, paraclinical and pathogenesis aspects of the relationship are examined. CTS is the most common neurological finding in RA, and incidences of RA, psoriatic arthritis and CTS are closely related. The association of CTS with systemic lupus erythematosus, Sjögren's syndrome, Behcet's disease and systemic sclerosis is weaker. In these cases, the prevalence of CTS is similar to that in the general population. As the occurrence of CTS is increasing, understanding the common mechanism and making an early diagnosis are required to limit pain and costs. When patients with RD present with symptoms such as wrist pain, tingling sensations or numbness in their fingers, CTS should be suspected. This suspicion should not be interpreted in terms of RD. To accurately evaluate patients with RD, a detailed electrophysiological examination should be included in the evaluation process. A diagnostic algorithm should include neuromuscular ultrasound or magnetic resonance imaging for patients with RD.

Is Ultrasonography a Reliable Approach for the Evaluation of Carpal Tunnel Syndrome in Patients With Mucopolysaccharidosis?

BACKGROUND

One of the most common causes of carpal tunnel syndrome (CTS) in childhood is mucopolysaccharidosis (MPS). While ultrasonography (US) can aid in the diagnosis of CTS in adult patients, there is limited experience of this in the pediatric group. We aimed to investigate the results of wrist ultrasonography, which may be a candidate alternative to electrophysiological examination.

METHODS

The participants were evaluated for symptoms, physical examination findings, electrophysiological tests and grayscale US. CTS was diagnosed in accordance with the American Academy of Orthopedic Surgeons Management of Carpal Tunnel Syndrome: Evidence-Based Clinical Practice Guideline.

RESULTS

Included in the study were 27 MPS patients aged 4.5-32 years and 30 healthy control subjects aged 4.3-26 years. Of the 54 wrists in the MPS group, 30 were diagnosed with CTS. The median cross-sectional area (CSA) at the proximal carpal tunnel, the CSA at the forearm, and the wrist-forearm ratio (WFR) were higher in the wrists of the MPS with CTS group than in those without CTS and the healthy control subjects. The WFR cutoff of ≥1.35, 56.6% (95% CI: 437.4-74.5) sensitivity, and 89.8% (95% CI: 81.0-95.5) specificity were consistent with a diagnosis of CTS (receiver operating characteristics analysis, area under the curve = 0.775, 95% CI: 0.673-0.877).

CONCLUSION

Although the US provides results with unsatisfactory specificity and sensitivity, it is a candidate for further investigation for the diagnosis of CTS because it is an innovative, noninvasive, and more accessible method. WFR value may produce more meaningful results than wrist or forearm nerve area measurements.

Efficacy of topical curcumin on mild to moderate carpal tunnel syndrome: a randomized double-blind, placebo-controlled clinical trial

OBJECTIVES

Recently, there has been a renewed interest in traditional medicine for carpal tunnel syndrome (CTS). Curcumin has been reported as an agent with antioxidant, anti-inflammatory, analgesic, and neuroprotective attributes. This study is one of the first investigations to assess the effect of curcumin gel on CTS.

METHODS

This study is a prospective, 8-week, randomized, placebo-controlled, parallel-group clinical trial. A total of 70 patients with CTS were analyzed. The intervention group (n = 35) received a topical curcumin gel and a night wrist splint and the control group (n = 35) received a placebo gel and a night wrist splint for 8 weeks. The primary outcome was the assessment of the symptom severity scale (SSS) and functional status scale (FSS) of the participants using the Boston Carpal Tunnel Questionnaire (BCTQ) after 8 weeks. In addition, all participants were evaluated by electrodiagnostic (EDX) test at baseline and after 8 weeks.

RESULTS

The mean scores of SSS demonstrated a significant decrease in the curcumin group compared to the placebo group; P-value= 0.021. The mean change score of SSS after the intervention was 12.45 ± 8.18 in curcumin and 3.28 ± 7.06 in the placebo group; P-value = 0.0001 and the mean change score of FSS were 6.24 ± 4.91 and 2.31 ± 4.95 in curcumin and placebo groups, respectively; P-value = 0.002. However, the EDX study showed no significant changes in both groups.

CONCLUSIONS

It seems that curcumin gel could be effective in the improvement of the symptom severity and daily activity of patients with CTS.

Effectiveness of prevention exercises protocol among office workers with symptoms of carpal tunnel syndrome

OBJECTIVES

Carpal tunnel syndrome (CTS) is common among office workers and limits functional hand ability and the ability to work. Carpal tunnel syndrome prevention programs implementation are still insufficient among office workers. In view of the fact that physical activity is the best method of preventing musculoskeletal complaints the aim of the study was to evaluate the effectiveness of prevention exercises protocol for hand and wrist pain among office workers.

MATERIAL AND METHODS

Study group consists form 62 office workers, reporting complaints of hand and wrist pain. Exercise group it was 49 subjects who performed the exercise protocol and the non-exercise group consisted of 13 subjects. An exercises program, consisting of 7 exercises. The program was planned for daily routine during 8 weeks. The effectiveness of the exercise program was assessed by physical parameters (hand grip and pinch grip strength, force of forearm muscles) and questionnaires (Visual Analog Scale pain scale, Carpal Tunnel Syndrome Symptom Severity Scale, and Carpal Tunnel Syndrome Functional Status Scale functional hand assessment questionnaires) were performed. Assessment was performed before and after the intervention.

RESULTS

Statistical analysis of the data showed significant changes in the value of measured hand grip of the right hand (Z = -2.85, p < 0.01). For pinch grip, changes were significant for both the right (Z = -2.12, p < 0.05) and the left hands (Z = -2.35, p < 0.05). Functional performance improved significantly in bought groups. There was no statistically significant change in the intensity of experienced pain.

CONCLUSIONS

The results of the study indicate that performing a preventive exercise program regularly has an effect on increasing forearm muscle strength in a group of office workers. Office workers with symptoms of CTS who exercised regularly had higher results in hand grip and pincer grip strength. Exercises do not affect the level of pain complaints, which may indicate a more complex etiology of pain perception in this study group. Int J Occup Med Environ Health. 2024;37(1):45-57.

Variant to gene mapping for carpal tunnel syndrome risk loci implicates skeletal muscle regulatory elements

BACKGROUND

Carpal tunnel syndrome (CTS) is a common disorder caused by compression of the median nerve in the wrist, resulting in pain and numbness throughout the hand and forearm. While multiple behavioural and physiological factors influence CTS risk, a growing body of evidence supports a strong genetic contribution. Recent genome-wide association study (GWAS) efforts have reported 53 independent signals associated with CTS. While GWAS can identify genetic loci conferring risk, it does not determine which cell types drive the genetic aetiology of the trait, which variants are "causal" at a given signal, and which effector genes correspond to these non-coding variants. These obstacles limit interpretation of potential disease mechanisms.

METHODS

We analysed CTS GWAS findings in the context of chromatin conformation between gene promoters and accessible chromatin regions across cellular models of bone, skeletal muscle, adipocytes and neurons. We identified proxy variants in high LD with the lead CTS sentinel SNPs residing in promoter connected open chromatin in the skeletal muscle and bone contexts.

FINDINGS

We detected significant enrichment for heritability in skeletal muscle myotubes, as well as a weaker correlation in human mesenchymal stem cell-derived osteoblasts. In myotubes, our approach implicated 117 genes contacting 60 proxy variants corresponding to 20 of the 53 GWAS signals. In the osteoblast context we implicated 30 genes contacting 24 proxy variants coinciding with 12 signals, of which 19 genes shared. We subsequently prioritized BZW2 as a candidate effector gene in CTS and implicated it as novel gene that perturbs myocyte differentiation in vitro.

INTERPRETATION

Taken together our results suggest that the CTS genetic component influences the size, integrity, and organization of multiple tissues surrounding the carpal tunnel, in particular muscle and bone, to predispose the nerve to being compressed in this disease setting.

FUNDING

This work was supported by NIH Grant UM1 DK126194 (SFAG and WY), R01AG072705 (SFAG & KDH) and the Center for Spatial and Functional Genomics at CHOP (SFAG & ADW). SFAG is supported by the Daniel B. Burke Endowed Chair for Diabetes Research. WY is supported by the Perelman School of Medicine of the University of Pennsylvania.

Identifying anatomic landmarks and median nerve characteristics for the analysis of persistent carpal tunnel syndrome using magnetic resonance imaging (MRI)

OBJECTIVE

Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy in the USA. In this study, we define anatomical landmarks to assess symptomatic and asymptomatic cohorts with persistent CTS using MRI imaging.

MATERIALS AND METHODS

Distal vs proximal incomplete release was determined using the distal most aspect of the hook of hamate and the distal wrist crease. An incomplete release showed the transverse carpal ligament (TCL) intact at either boundary. Twenty-one patients with persistent CTS were analyzed for incomplete release, median nerve enlargement and T2 signal hyperintensity, and flattening ratio using postoperative wrist MRI. These findings were compared to a ten-patient asymptomatic persistent CTS control group. Fisher's exact and a Student's two-tailed t-tests were used to determine statistical significance.

RESULTS

In the symptomatic persistent CTS group, 13 (61.9%) incomplete releases were identified, 5 (38.5%) incomplete distally, and 1 (7.7%) incomplete proximally. There was no statistical significance in the rate of incomplete releases when compared to the asymptomatic group (p = 1.00). T2 signal hyperintensity and enlargement at the site of release showed no statistical significance, (p = 0.319 and p = 0.999, respectively). The mean flattening ratio at the site of release in the symptomatic group (2.45 ± 0.7) was statistically significant compared to the asymptomatic group (1.48 ± 0.46), (p = 0.007).

CONCLUSION

Utilizing the established landmarks, the full length of the TCL can be assessed via MRI. Additionally, evaluation of the median nerve flattening ratio at the level of the incomplete release may be utilized as an aid to the clinical management of persistent CTS.

Effects of kinesio taping with and without active release technique in carpal tunnel syndrome

BACKGROUND

Kinesio taping is used as a conservative treatment for carpal tunnel syndrome and the active release technique is also effective.

OBJECTIVE

The purpose of the present study was to compare the effects of kinesio taping with and without the active release technique on pain, grip strength, functional disability and range of motion in patients with carpal tunnel syndrome.

METHODS

It was a randomized controlled trial. Thirty-two patients with carpal tunnel syndrome were randomly allocated to two groups: Group A received kinesio taping with the active release technique for 4 weeks (3 days/week); Group B received kinesio taping alone for 4 weeks (5 days/week). Outcome measures were the Boston Carpal Tunnel Syndrome Questionnaire, a numeric pain rating scale, goniometry and hand-held dynamometry. SPSS software, version 25, was used for data analysis.

RESULTS

Normal distribution was assessed on the Shapiro-Wilk test and parametric tests were applied. Independent t-test results showed that patients who received kinesio taping with the active release technique showed significantly greater improvement (p < 0.05) in pain, functional status and range of motion than the group that received kinesio taping alone. Within-group analysis (paired t-test) showed that both groups significantly improved (p < 0.05) in all outcome measures.

CONCLUSION

Kinesio taping with the active release technique procured significantly greater improvement in pain, range of motion and functional disability than kinesio taping alone.

CLINICALTRIALS

gov registration number: 789.

Carpal tunnel syndrome

Median neuropathy at the wrist, commonly referred to as carpal tunnel syndrome (CTS), is the most common entrapment neuropathy. It is caused by chronic compression of the median nerve at the wrist within the space-limited carpal tunnel. Risk factors that contribute to the etiology of compression include female gender, obesity, work-related factors, and underlying medical conditions, such as hypothyroidism, pregnancy, and amyloidosis. The diagnosis is made on clinical grounds, although these can be confounded by anatomical variations. Electrodiagnostic studies, which are specific and sensitive in diagnosing CTS, support the diagnosis; however, a subgroup may present with normal results. The advent of imaging techniques, including ultrasound and MRI, further assists the diagnostic process. The management of CTS is divided into the nonsurgical approaches that include hand therapy, splinting and corticosteroid injection, and surgical decompression of the carpal tunnel. Although several surgical techniques have been developed, no one method is more effective than the other. Each of these management approaches are effective at providing symptom relief and are utilized at different severities of the condition. There is, however, a lack of consensus on standardized diagnostic criteria, as well as when and to whom to refer patients for surgery.

Awareness of Carpal Tunnel Syndrome Among the Middle-Aged Population in Riyadh, Saudi Arabia

Background Carpal tunnel syndrome (CTS), a common and often underdiagnosed condition, imposes a significant burden on individuals, particularly in middle-aged populations. This study aims to assess the awareness and prevalence of CTS among middle-aged residents in Riyadh, highlighting the crucial need for targeted educational initiatives to address knowledge gaps. Methodology A cross-sectional study design was employed to capture a snapshot of CTS awareness and prevalence among the middle-aged population in Riyadh, Saudi Arabia. Participants aged 40-60 residing in Riyadh were included. A self-reported questionnaire gathered data on demographics, CTS diagnosis, and awareness levels regarding symptoms, risk factors, treatment, and the impact of CTS. Statistical analysis included descriptive statistics and Chi-squared tests. Results We collected 415 valid responses to the questionnaire. The demographic profile revealed a balanced gender distribution, with 48.4% (n=201) males and 51.6% (n=214) females, and a majority (66.5%; n=276) within the 40-50 age range. A substantial 87.2% (n=362) reported no prior CTS diagnosis. Neuroimaging studies were infrequently conducted at 15.9% (n=66). Participants exhibited significant knowledge gaps, notably in the awareness of CTS diagnosis 66.3% (n=275) uncertainty, symptoms 55.4% (n=230) lack of knowledge, and risk factors 54.7% (n=227) lack of awareness. The results indicated uncertainty regarding the relationship between CTS and diabetes 63.9% (n=265) and knowledge gaps on anesthesia methods for CTS operations 64.1% (n=294). The association between age and CTS diagnosis was significant (p-value 0.004), while awareness did not significantly vary with gender or age. Conclusion This study unveils a substantial lack of awareness about CTS among the middle-aged population in Riyadh, emphasizing the need for targeted educational interventions. The prevalence of CTS remains underreported, with a notable gap in understanding symptoms, risk factors, and available treatments; the findings underscore the vital importance of targeted educational programs designed to raise public awareness, bridge information gaps, and empower individuals to make informed decisions about their hand health.

Persistent Pain as an Early Indicator for Operative Carpal Tunnel Revision after Primary Release: A Retrospective Analysis of Recurrent and Persistent Carpal Tunnel Syndrome

BACKGROUND

Prolonged symptoms of carpal tunnel syndrome (CTS) after primary carpal tunnel release (CTR) can reduce the quality of life and lead to multiple referrals across specialties. The following study aimed to identify differences in symptoms, signs, and intraoperative findings between recurrent and persistent CTS cases to avoid undesired outcomes after primary CTR.

METHODS

A retrospective analysis was conducted on revision CTRs performed between 2005 and 2015 using literature-based definitions for recurrent (a relapse of symptoms occurs following a symptom-free period of ≥3 months) and persistent (symptoms persisting longer than three months after surgical release) CTS. The parameters assessed were symptoms, clinical signs, and intraoperative findings.

RESULTS

Out of 53 cases, 85% (n = 45) were external referrals, whereby our own revision rate was 0.67% (n = 8/1199). Paresthesia and numbness were frequent in both groups; however, abnormal postoperative pain was reported more often in persistent cases (86%; n = 30/35) in comparison to recurrent cases (50%; n = 9/18; p = 0.009). Scarring around the median nerve was observed in almost all recurrent cases (94%; n = 17/18) and in 40% (n = 14/35) of persistent cases (p < 0.001). Incomplete division of the palmar ligament was the primary cause for revision in the persistent cohort (49%; n = 17/35).

CONCLUSIONS

For patients experiencing symptoms for more than three months after CTR, primarily presenting as pain, it is advisable to consider referring the patient to a certified hand clinic for additional evaluation.

Endoscopic carpal surgery in carpal tunnel syndrome: A systematic review

Objective

Endoscopic carpal tunnel release has become increasingly popular and has shown the advantage of early recovery of hand function with minimal morbidity. In this systematic review, we aimed to summarize the currently available data and describe the reported advantages and disadvantages of endoscopic carpal tunnel surgery for treating carpal tunnel syndrome.

Methods

In this study, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, which is a set of reporting requirements for systematic reviews and meta-analyses. The search strategy with MeSH terms was "MeSH (carpal tunnel syndrome) AND (endoscopic)" Filters: in the last 5 years, English-on February 27th, 2022. A total of 131 articles fulfilled the first screening criteria. A detailed analysis of those articles identified 39 that matched the criteria, of which 14 were considered appropriate for this analysis after applying the complete inclusion and exclusion criteria.

Results

A total of 14 studies met the eligibility criteria. Analysis of those studies found that all types of portals in endoscopic carpal tunnel release reduced postoperative pain at a short-term follow-up. There was no evidence to suggest the superiority of the single- or two-portal techniques in terms of outcomes. In terms of pain relief, symptom resolution, patient satisfaction, duration to return to work, and adverse events, this early use of endoscopic carpal tunnel release produced satisfactory outcomes. Further studies comparing the number of portals are needed.

Conclusion

Endoscopic carpal tunnel surgery for treating carpal tunnel syndrome is effective and both single- and dual-portal techniques provide advantages in terms of early recovery and minimal morbidity.

Bilateral Idiopathic Carpal Tunnel Syndrome: Clinical-Functional Characterization and Efficacy of Two Combined Postoperative Physiotherapeutic Treatments

OBJECTIVE

To evaluate the efficacy of combined association instrument myofascial mobilization (IASTM) and stretching in patients with idiopathic bilateral carpal tunnel syndrome (CTS) operated on one hand and to analyze the response of the operated (OH) and non-operated (NH) hand according to the sequence of therapies. Research on these parameters has not yet been found in the literature.

METHODS

Randomized controlled crossover study with 43 participants using the objective and subjective outcome variables. Patients were randomly assigned to two groups: starting with stretching followed by IASTM and starting with IASTM followed by stretching. Then patients underwent surgery on the hand with more severe involvement and physical therapy rehabilitation was started 30 days after for a period of 4 weeks. After the 1-week interval the participants who started with stretching were referred to IASTM and vice versa, following the same previous patterns. The outpatient reassessments took place at 3 to 6 months. Crossover ANOVA and effect sizes were used as analysis methods.

RESULTS

Time was the most significant outcome for all variables both during therapies and at 6-month follow-up. Regarding response to the combined therapies between OH and NH, there were differences for both OH and NH, with the greatest impact on NH for the palmar grip and VAS variables. The treatment sequences were significant for pain on the NH and mental SF-12, suggesting that starting with IASTM followed by stretching had a superior outcome for these outcomes.

CONCLUSION

The combination of IASTM with stretching, used in the postoperative period of bilateral idiopathic CTS, proved to be supplementary, with significant results and large effect sizes for most of the outcomes assessed, both during the time of application of the therapies and in the 6-month follow-up for both hands, and may constitute a viable therapeutic alternative for this population.

Comparison efficacy of ultrasound-guided needle release plus corticosteroid injection and mini-open surgery in patients with carpal tunnel syndrome

This retrospective study was to compare clinical outcomes of ultrasound-guided needle release with corticosteroid injection vs. mini-open surgery in patients with carpal tunnel syndrome (CTS). From January 2021 to December 2021, 40 patients (40 wrists) with CTS were analyzed in this study. The diagnosis was based on clinical symptoms, electrophysiological imaging, and ultrasound imaging. A total of 20 wrists were treated with ultrasound-guided needle release plus corticosteroid injection (Group A), and the other 20 wrists were treated with mini-open surgery (Group B). We evaluated the Boston carpal tunnel questionnaire, electrophysiological parameters (distal motor latency, sensory conduction velocity, and sensory nerve action potential of the median nerve), and ultrasound parameters (cross-sectional area, flattening ratio, and the thicknesses of transverse carpal ligament) both before and 3 months after treatment. Total treatment cost, duration of treatment, healing time, and complications were also recorded for the two groups. The Boston carpal tunnel questionnaire and electrophysiological and ultrasound outcomes at preoperatively and 3 months postoperatively had a significant difference for each group (each with P &lt; 0.05). There were no complications such as infection, hemorrhage, vascular, nerve, or tendon injuries in both groups. Ultrasound-guided needle release and mini-open surgery are both effective measures in treating CTS patients. Ultrasound-guided needle release plus corticosteroid injection provides smaller incision, less cost, less time of treatment, and faster recovery compared with mini-open surgery. Ultrasound-guided needle release plus corticosteroid injection is better for clinical application.

Comparison Between Distal and Proximal Approaches for Local Corticosteroid Injection in Carpal Tunnel Syndrome Management: A Randomized Controlled Trial

BACKGROUND

The present, open-labeled study aimed to compare the distal approach (DA) for local corticosteroid injection (LCI) with the conventional proximal approach (PA) in alleviating the symptom and improving the electrodiagnostic parameters of the patients with carpal tunnel syndrome (CTS).

METHODS

A total of 60 participants with nonsevere CTS were included in the present randomized controlled trial (RCT), of which 29 and 31 were assigned to the DA and PA groups, respectively. Each group received a single, landmark-guided injection of local methylprednisolone. The participants were assessed preintervention and 3 months later using the measures of visual analog scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), hand grip strength, and nerve conduction study (NCS).

RESULTS

Following a 3-month follow-up, both groups had significant improvements in VAS, both functional and severity subscales of BCTQ, hand grip strength, and some electrodiagnostic parameters (all P-values < .05). Moreover, the DA group had a significantly lower procedure duration than the PA group (9.80 ± 1.12 vs. 27.61 ± 1.77; P < .001).

CONCLUSIONS

LCI using the DA should be considered a feasible, safe, and effective therapeutic method in patients with mild to moderate CTS. It had a shorter procedure duration than conventional PA, while their clinical and electrophysiological results were similar.

Utilidad de la ecografía en la cirugía de la mano: Parte II

En los últimos años, con los avances técnicos en la ecografía, aumentó la calidad de las imágenes, lo que ha permitido a los cirujanos mejorar su capacidad de evaluar la mano y la muñeca. Las infiltraciones ecoguiadas en cirugía de mano son más precisas y seguras en comparación con las infiltraciones sin el uso de ecografía. El desarrollo de la técnica de ecografía y de transductores de alta resolución nos ayuda a realizar procedimientos ecoguiados, como el tratamiento del dedo en gatillo, la liberación del síndrome del túnel carpiano, y la aponeurotomía en la enfermedad de Dupuytren. El objetivo de este trabajo es describir las técnicas ecográficas en el tratamiento de las patologías de la mano y el estado del arte de las cirugías ecoguiadas de la mano y sus resultados.

Pathophysiology, Diagnosis, Treatment, and Genetics of Carpal Tunnel Syndrome: A Review

Carpal tunnel syndrome (CTS) is a common peripheral canalicular nerve entrapment syndrome in the upper extremities. The compression of or injury to the median nerve at the wrist as it passes through a space-limited osteofibrous carpal canal can cause CTS, resulting in hand pain and impaired function. The present paper reviews the literature on the prevalence, pathology, diagnosis, treatment, and risk factors of CTS in conjunction with the role of genetic factors in CTS etiology. CTS diagnosis is primarily linked with clinical symptoms; still, it is simplified by sophisticated approaches such as magnetic resonance imaging and ultrasonography. CTS symptoms can be ameliorated through conservative and surgical strategies. The exact CTS pathophysiology needs clarification. Genetic predispositions to CTS are augmented by various variants within genes; however, CTS etiology could include risk factors such as wrist movements, injury, and specific conditions (e.g., age, body mass index, sex, and cardiovascular conditions). The high prevalence of CTS diminishes the quality of life of its sufferers and imposes costs on health systems, hence the significance of research and clinical trials to elucidate CTS pathogenesis and develop novel therapeutic targets.

Application study of infrared free-electron lasers towards the development of amyloidosis therapy

Amyloidosis is known to be caused by the deposition of amyloid fibrils into various biological tissues; effective treatments for the disease are little established today. An infrared free-electron laser (IR-FEL) is an accelerator-based picosecond-pulse laser having tunable infrared wavelengths. In the current study, the irradiation effect of an IR-FEL was tested on an 11-residue peptide (NFLNCYVSGFH) fibril from β2-microglobulin (β2M) with the aim of applying IR-FELs to amyloidosis therapy. Infrared microspectroscopy (IRM) and scanning electron microscopy showed that a fibril of β2M peptide was clearly dissociated by IR-FEL at 6.1 µm (amide I) accompanied by a decrease of the β-sheet and an increase of the α-helix. No dissociative process was recognized at 6.5 µm (amide II) as well as at 5.0 µm (non-specific wavelength). Equilibrium molecular dynamics simulations indicated that the α-helix can exist stably and the probability of forming interchain hydrogen bonds associated with the internal asparagine residue (N4) is notably reduced compared with other amino acids after the β-sheet is dissociated by amide I specific irradiation. This result implies that N4 plays a key role for recombination of hydrogen bonds in the dissociation of the β2M fibril. In addition, the β-sheet was disrupted at temperatures higher than 340 K while the α-helix did not appear even though the fibril was heated up to 363 K as revealed by IRM. The current study gives solid evidence for the laser-mediated conversion from β-sheet to α-helix in amyloid fibrils at the molecular level.

The Radiographic Risk Factors Predicting Occurrence of Idiopathic Carpal Tunnel Syndrome in Simple Wrist X-ray

The causes of carpal tunnel syndrome are complex. However, little is known about the risk factors for carpal tunnel syndrome occurrence on simple radiographic images. To determine the X-ray imaging factors that can predict idiopathic carpal tunnel syndrome occurrence, we compared a group diagnosed with idiopathic carpal tunnel syndrome who received carpal tunnel release with a control group that had no symptoms. The simple wrist X-ray findings of 75 patients diagnosed with idiopathic carpal tunnel syndrome and 87 patients selected for the control group were evaluated. All the carpal tunnel syndrome patients were diagnosed based on clinical symptoms and nerve conduction studies. Anteroposterior and lateral radiographs of the wrists were taken in all the groups. The radial inclination, volar tilt, ulnar variance, radiolunate angle, and lunate-to-axis-of-radius distance were measured. Data were measured using two independent raters. After calculating the average of each value, the two groups were statistically compared. The diagnostic performance of statistically different figures was confirmed by drawing receiver operator characteristic curves. There was a significant difference in the radiolunate angle and lunate-to-axis-of-radius distance between the two groups (p < 0.01 and p = 0.028, respectively). The odd ratios for each parameter were 1.052 and 1.319, respectively. The area under the receiver operator characteristic curves were 0.715 and 0.601, respectively. In this study, radiolunate angle and lunate-to-axis-of-radius distance were useful as radiographic diagnostic tools. In other words, excessive dorsiflexion and volar displacement of the lunate can be considered as risk factors that may cause idiopathic carpal tunnel syndrome in the future.

The Pathological Links between Adiposity and the Carpal Tunnel Syndrome

An association between obesity and carpal tunnel syndrome is found in many epidemiological studies. Therefore, there is a need to evaluate the physiopathological links that could explain the association between these two entities. Ectopic adipose tissue is responsible for metabolic syndrome and inflammation, and is a major risk factor for diabetes and cardiovascular diseases. Taking these elements into consideration, we conducted an extensive literature revision of the subject, considering as ectopic fat-related mechanisms the following: (a) the direct compression and the association with the metabolic syndrome of the fat deposition around the wrist, (b) the insulin resistance, dyslipidemia, inflammatory, and oxidative mechanisms related to the central deposition of the fat, (c) the impaired muscle contraction and metabolism related to myosteatosis. Each section presents the cellular pathways which are modified by the ectopic deposition of the adipose tissue and the impact in the pathogeny of the carpal tunnel syndrome. In conclusion, the experimental and clinical data support the epidemiological findings. Efforts to reduce the obesity epidemics will improve not only cardio-metabolic health but will reduce the burden of the disability-free life expectancy due to the carpal tunnel syndrome.

Local Corticosteroid Injections versus Surgical Carpal Tunnel Release for Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

Introduction: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. This meta-analysis compared local steroid injections (LSIs) versus carpal tunnel release (CTR) for the management of CTS. Neurophysiological parameters, patient-reported outcome measures (PROMs), and the complication rate were investigated. We hypothesized that LSIs may represent an effective and safe alternative to surgical management. Methods: This systematic review was conducted according to the 2020 PRISMA statement. All the clinical investigations comparing LSIs versus CTR for carpal tunnel syndrome were accessed. In March 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar, and Embase. No time constrains were used for the search. The risk of bias and statistical analyses were conducted using the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen). Results: Data from 1096 procedures were retrieved. The mean follow-up was 12.3 (1 to 58) months. The mean age of the patients was 51.1 ± 4.6. Nocturnal paraesthesia (p < 0.0001) and visual analogue scale (p < 0.0001) were greater in the LSIs cohort. No difference was found in the functional (p = 0.2) and symptom (p = 0.4) subscales of the Boston Carpal Tunnel Questionnaire (BCTQ), median nerve distal motor latency (p = 0.9), median nerve motor amplitude (p = 0.7), median nerve sensory conduction velocity (p = 0.4), or median nerve sensory amplitude (p = 0.3). No difference was found in terms of minor complications (p = 0.9). No major complications were observed within the duration of follow-up. Conclusion: Both CTR and LSIs were effective and feasible in reducing symptoms of carpal tunnel syndrome. Though LSIs led to greater pain relief, this superiority was not permanent. Irrespective of the severity of the symptoms, current evidence suggests that a cycle of LSIs may be considered in patients with CTS. However, patients must be aware that LSIs may not be the definitive therapy, and CTR should be recommended.

Three-Dimensional Carpal Arch Morphology Using Robot-Assisted Ultrasonography

OBJECTIVE

The morphology of the carpal arch implicates the available space for the median nerve within the carpal tunnel. The purposes of this study were to 1) reconstruct the three-dimensional (3D) carpal arch by robot-assisted ultrasonography with a linear array transducer using cadaveric hands, and 2) investigate the 3D morphological properties of the carpal arch.

METHODS

An ultrasound probe with two-dimensional (2D) linear array was integrated on a robotic arm and maneuvered over the cadaveric carpal tunnels to scan the entire transverse carpal ligament and its osseous attachments to carpal bones. The acquired series of 2D ultrasound images together with robot positioning were utilized to reconstruct the 3D carpal arch for morphometric analyses.

RESULTS

Total carpal arch volume was 1099.4 ± 163.2 mm³ with the distal, middle, and proximal regions contributing 18.2 ± 1.5%, 32.7 ± 1.2%, and 49.1 ± 2.3%, respectively. The ligament surface area was 420.1 ± 63.9 mm². The carpal arch width, height, curvature, length, area, and palmar bowing index progressively increased from the distal to proximal locations within the tunnel (p < 0.01).

CONCLUSION

The incorporation of the robot technology with the ultrasound system advanced the applications of traditional 2D ultrasound imaging for a 3D carpal arch reconstruction, allowing for comprehensive morphological assessment of the carpal arch.

SIGNIFICANCE

The developed workflow can be used for the reconstruction and analysis of other anatomical features in vivo.

Can the Boston Carpal Tunnel Syndrome Questionnaire Be Used as a Screening Tool Among a Potentially High-Risk Population in Singapore?

Introduction  Carpal tunnel syndrome (CTS) causes significant morbidity with delayed diagnosis or management. The Boston Carpal Tunnel Questionnaire (BCTQ) is validated for monitoring CTS following diagnosis; however, it has not been trialed in a screening capacity. The study aimed to determine whether it can be utilized when screening a focused population in Singapore. Materials and Methods  A single-center survey-based study was undertaken prospectively to identify whether positive symptoms could be identified among nursing and administrative staff. Results  A total of 605 staff responded. Positive symptoms were identified in 317 (52.4%) of participants and 23 (3.8%) reported them to be severe. Functional limitations were detected in 157 (26.0%) of participants with 5 (0.8%) reporting these as severe. Positive symptoms (84.9%) and functional limitations (81.5%) were more prevalent among nursing staff. Cronbach's α scores (0.896 for symptoms and 0.84 for functional limitations) suggested good reliability in matching symptoms and functional limitations. Conclusion  The BCTQ can potentially be implemented as a screening tool for CTS among those without a prior diagnosis. It has a greater depth of questioning with symptomatic and functional limitations considered, and in situations where a formal diagnosis is subsequently made, the same tool can be subsequently used for progression tracking pre- and post-treatment. Level of Evidence  This is a Level II study.

Application of shear wave elastography and median nerve cross-section area in the diagnosis and staging of carpal tunnel syndrome: a case-control study

Purpose

Imaging is gaining a more prominent role in the diagnosis of carpal tunnel syndrome (CTS), especially ultrasonography. Shear wave elastography (SWE) is a novel qualitative method to study mechanical changes in tissue. In this study, we aim to assess the role of SWE in diagnosing and staining of the disease.

Material and methods

A total of 124 wrists were included in the study. Seventy wrists had CTS, and 54 were included as the control group. All of the wrists with CTS had staging done with nerve conduction study. All patients underwent ultrasonography by an expert radiologist and had the SWE and cross-section of the median nerve determined. These values were compared among the 2 groups and different stages of CTS. The receiver operating characteristic curve was utilized to assess the diagnostic role of each of the variables.

Results

Cross-section area (CSA) and SWE were significantly different between the 2 groups (p = 0.0001). CSA was also significantly different among various stages of CTS. SWE was not significantly different among moderate and severe stages of CTS. Both of the variables had a good ability to distinguish mild CTS from healthy wrists (p = 0.0001).

Conclusion

SWE can be used in diagnosing CTS and in the staging of the disease.

The effects of vitamin D supplementation in carpal tunnel syndrome treatment outcomes: a systematic review

PURPOSE

Vitamin D deficiency is related to carpal tunnel syndrome symptoms. Correcting vitamin D levels by supplementation was supposed to improve carpel tunnel symptoms, though there is a lack of aggregated data about treatment outcomes. This study aimed to examine whether vitamin D supplementation could improve the treatment outcomes in carpal tunnel syndrome patients.

METHODS

A comprehensive search of the PubMed, Cochrane Library, Scopus, and Web of Science databases for articles on vitamin D and carpel tunnel syndrome from January 2000 to March 2021 was performed. The article screening and data extraction were performed by two investigators independently with blinding to decisions on selected studies. All included studies had assessed the quality of evidence using the Methodological Index for Non-Randomized Studies (MINORS) scoring system.

RESULTS

We retrieved four studies that met the eligibility criteria. The treatment outcomes were evaluated by visual analog scale (124 wrists), functional scores (176 patients), muscle strength (84 patients), and nerve conduction velocity (216 wrists). After vitamin D supplementation, two studies reported improved pain scores and nerve conduction velocity, and three studies showed enhancement of functional status.

CONCLUSION

Vitamin D administration could offer favorable outcomes in pain improvement, better functional status, and increased sensory conduction velocity in carpal tunnel syndrome. However, there is to date no recommendations concerning a standardized dose or duration of vitamin D administration in carpal tunnel syndrome; prescribing vitamin D at the usual appropriate dose is suggested as an additional treatment in patients with mild to moderate carpel tunnel symptoms.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

MRI of carpal tunnel syndrome: before and after carpal tunnel release

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome. Magnetic resonance imaging (MRI) is increasingly used to diagnose CTS, exclude secondary causes of CTS, and investigate patients with persistent symptoms after carpal tunnel release. Median nerve compression may also be either subclinical in the early stages or present with atypical symptoms. Radiologists are therefore not infrequently the first to alert clinicians as to the possibly of subclinical or atypical CTS. This review shows the normal and abnormal appearances of the carpal tunnel before and after CTR.

Comparison of low power laser and kinesio taping for the treatment of carpal tunnel syndrome: A prospective randomized study

BACKGROUND

Although carpal tunnel syndrome (CTS) is a common neuromuscular disorder, studies on its conservative treatment are inadequate and contradictory.

OBJECTIVES

This study aimed to investigate and compare the effectiveness of low power laser therapy (LPLT) and Kinesio taping (KT) for the treatment of CTS.

METHODS

Sixty patients with CTS were included in this study. One group received 15 sessions of KT, and the second group underwent 15 sessions of LPLT within three weeks. All patients were assessed with hand grip strength (HGS), Visual Analogue Scale (VAS)-pain, Douleur Neuropathique-4 (DN4) score, Boston Questionnaire (BQ), and electroneuromyography before and after treatment.

RESULTS

Before treatment, all clinical and neurophysiological parameters were similar between the groups. After treatment, both groups significantly improved in terms of HGS, VAS-pain, DN4, and BQ. However, the LPLT group had significantly better HGS, VAS-pain, DN4, and BQ than the KT group. In addition, while median nerve motor distal latency and median nerve sensory conduction velocity improved significantly with treatment in both groups, the LPLT group's improvement was significantly better than that of the KT group.

CONCLUSIONS

In patients with CTS, both LPLT and KT were effective treatments. However, the LPLT group had significantly better improvements than the KT group.

Platelet-rich plasma in non-operative management of mild to moderate carpal tunnel syndrome - A systematic review & meta-analysis of short-term outcomes

Background

To perform an updated systematic review with meta-analysis on trials focusing on patient-reported outcome measures (PROMs), nerve conduction studies (NCS) result and cross sectional area (CSA) measurements of those who underwent PRP injection for mild to moderate CTS, versus a control.

Conclusion

This study indicates that there may be a potential role for the use of PRP in the non-operative management of mild to moderate CTS results in improvements in pain scores, functional outcomes as well as CSA measurements of the MN at short-term follow-up. However, PRP does not result in improvements in NCS.

Level of evidence

II; Systematic Review & Meta-Analysis of Prospective Trials;

Fundamentals and Current Strategies for Peripheral Nerve Repair and Regeneration

A body of evidence indicates that peripheral nerves have an extraordinary yet limited capacity to regenerate after an injury. Peripheral nerve injuries have confounded professionals in this field, from neuroscientists to neurologists, plastic surgeons, and the scientific community. Despite all the efforts, full functional recovery is still seldom. The inadequate results attained with the "gold standard" autograft procedure still encourage a dynamic and energetic research around the world for establishing good performing tissue-engineered alternative grafts. Resourcing to nerve guidance conduits, a variety of methods have been experimentally used to bridge peripheral nerve gaps of limited size, up to 30-40 mm in length, in humans. Herein, we aim to summarize the fundamentals related to peripheral nerve anatomy and overview the challenges and scientific evidences related to peripheral nerve injury and repair mechanisms. The most relevant reports dealing with the use of both synthetic and natural-based biomaterials used in tissue engineering strategies when treatment of nerve injuries is envisioned are also discussed in depth, along with the state-of-the-art approaches in this field.

Effect of Platelet-Rich Plasma Injection on Mild or Moderate Carpal Tunnel Syndrome: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To evaluate efficacy of platelet-rich plasma (PRP) injection in carpal tunnel syndrome (CTS), we conducted this meta-analysis, as well as proposed a protocol for its application in curative processes.

Methods

All randomized controlled trials (RCTs) of PRP for the management of mild or moderate CTS were included in this study. Database search was conducted from study inception to July 2020, including PubMed, Embase, Web of Science, and Cochrane Library. We used visual analogue scores (VAS) and the Boston Carpal Tunnel Questionnaire (BCTQ) as evaluation tools for primary outcomes. Second outcomes comprised cross-sectional area (ΔCSA) and electrophysiological indexes including distal motor latency (DML), sensory peak latency (SPL), motor nerve conduction velocity (MNCV), sensory nerve conduction velocity (SNCV), compound muscle action potential (CMAP), and sensory nerve action potential (SNAP). The pooled data were analyzed using RevMan 5.3. Subgroup and sensitivity analyses were conducted with the evidence of heterogeneity. Egger' test was used to investigate publication bias.

Results

9 RCTs were finally screened out with 434 patients included. Control groups comprised corticosteroid injection in 5 trials, saline injection in 1 trial, and splint in 3 trials. At the 1st month after follow-up, only ΔCSA between the PRP group and the control group showed significant difference (P < 0.05). In the 3rd month, there were statistically significant differences in VAS, BCTQ, SPL, SNCV, and ΔCSA between two groups (P < 0.05), while no statistically significant differences were found in the remaining outcomes. In the 6th month, there were statistically significant differences at BCTQ (P < 0.05) in primary outcomes and ΔCSA (P < 0.05) in secondary outcomes between two groups. As to adverse events in PRP injection, only one study reported increased pain sensation within 48 h after injections.

Conclusion

This systematic review and meta-analysis demonstrates that the PRP could be effective for mild to moderate CTS and superior to traditional conservative treatments in improving pain and function and reducing the swelling of the median nerve for a mid-long-term effect. To some extent, the electrophysiological indexes also improved after PRP injection compared with others conservative treatments.

Nerve wrapping for recurrent compression neuropathy: A systematic review

BACKGROUND

The recurrence of symptoms following primary nerve compression surgery can occur in up to 25% of cases. Nerve wrapping can be utilised for revision surgery. An ideal barrier should minimise the chance of fibrosis, scarring and allow for adequate nerve gliding. This review evaluates the use of autologous or commercially available allograft and xenograft options as barriers against nerve scarring following revision surgery.

METHODS

PubMed, Ovid Embase and Cochrane databases were searched using the All Fields Index. Nine hundred titles underwent title screening with 11 studies being included in the final analysis. The risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. PRISMA guidelines were followed at all stages and the review was registered with PROSPERO (CRD 42020182818).

RESULTS

The 11 studies comprised of all case series. In total, 114 patients were included, with ages ranging from 28 to 90. Previously, the number of revision surgeries ranged from 0 to 5. Autologous veins were used in 6 studies, collagen in 3 studies and human amniotic membrane in 2 studies. Improvements in subjective and objective outcomes were seen with all wrap types. Pain was the most common residual symptom (46% of patients). The most common complication was pain at the donor site following vein harvest (19% of patients).

CONCLUSION

This is the first systematic review to summarise the outcomes of nerve wraps for revision compression neuropathy. While improvements in outcomes were reported, further comparative studies are needed to determine the best nerve wrap.

High prevalence of carpal tunnel syndrome in individuals with rare nerve growth factor-beta mutation

In Sweden, a large family with a point mutation in the nerve growth factor-beta gene has previously been identified. The carriers of this mutation have reduced small-fibre density and selective deficits in deep pain and temperature modalities. The clinical findings in this population are described as hereditary sensory and autonomic neuropathy type V. The purpose of the current study was to investigate the prevalence of carpal tunnel syndrome in hereditary sensory and autonomic neuropathy type V based on clinical examinations and electrophysiological measurements. Furthermore, the cross-sectional area of the median nerve at the carpal tunnel inlet was measured with ultrasonography. Out of 52 known individuals heterozygous for the nerve growth factor-beta mutation in Sweden, 23 participated in the current study (12 males, 11 females; mean age 55 years; range 25–86 years). All participants answered a health questionnaire and underwent clinical examination followed by median nerve conduction study in a case–control design, and measurement of the nerve cross-sectional area with ultrasonography. The diagnosis of carpal tunnel syndrome was made based on consensus criteria using patient history and nerve conduction study. The prevalence of carpal tunnel syndrome in the hereditary sensory and autonomic neuropathy group was 35% or 52% depending on whether those individuals who had classic symptoms of carpal tunnel syndrome but negative nerve conduction studies were included or not. Those who had a high likelihood of carpal tunnel syndrome based on classic/probable patient history with positive nerve conduction study had a significantly larger median nerve cross-sectional area than those who had an unlikely patient history with negative nerve conduction study. The prevalence of carpal tunnel syndrome was 10–25 times higher in individuals heterozygous for the nerve growth factor-beta mutation than the general Swedish population. Further studies are needed to better understand the underlying pathophysiological mechanisms.

Clinico-radiological review of peripheral entrapment neuropathies - Part 1 upper limb

PURPOSE

This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies.

METHODS

The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies.

RESULTS

Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies.

CONCLUSION

It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.

Platelet-rich plasma injection versus surgical and medical treatment of mild-moderate carpal tunnel syndrome

Abstract

Carpal tunnel syndrome (CTS) accounts for approximately 90% of peripheral entrapment neuropathy cases. Treatments of CTS as splinting, corticosteroid injection, and surgery are not 100% effective, and alternative treatments are worth exploring. Surgery indicated in patients with persistent numbness, pain, and motor dysfunction. Empirical evidence indicates that many patients with CTS respond to anti-inflammatory medications. Recently, major attention has been drawn to platelet-rich plasma (PRP) for its possible effects on axon regeneration and neurological recovery.

Objectives

To evaluate the therapeutic efficacy of single ultrasound guided PRP injection of CTS versus surgical procedures and medical treatment in patients with mild-moderate CTS regarding pain relief and function improvement.

Methods

Thirty patients were injected in the carpal tunnel with single ultrasound-guided PRP (1–2 ml) injections; 30 patients went to surgical procedure, and 30 patients received conventional medical treatment and hand support. They were followed by using VAS (visual analogue scale), Boston questionnaire for CTS, and nerve conduction study for clinical improvement.

Results

Both groups of patients who had received PRP injection and who underwent to surgery showed improvements in their scores of evaluation parameters at 6 months post intervention, while the third group that received medical treatment shows insignificant improvement at 6 months post treatment.

Conclusion

PRP can be considered as a safe, less invasive, and long-lasting alternative to surgery and effective with one shot session compared to medical treatment in management of mild-moderate CTS.

Trial registration

Clinical trial.govID: NCT04235426.

Unique protocol ID:1472.

Verification date: January 2020.

Carpel tunnel syndrome: A link with vitamin D and calcium

Carpal tunnel syndrome (CTS) and vitamin D deficiency are two conditions that cause chronic pain and are thus associated with psychological issues as well. The aim of the present study was to evaluate vitamin D levels, daily calcium intake, musculoskeletal pain and psychological symptoms in patients with CTS. The study included 48 patients with CTS and age-sex matched controls. Serum vitamin D levels were measured, and psychological symptoms were assessed using a Hospital Anxiety and Depression Scale. A Pain DETECT questionnaire was used to assess musculoskeletal pain (MSP) sites and severity. The results showed that vitamin D deficiency was considerably more prevalent in patients with CTS (95.8%) compared with controls (22.9%). Clinical anxiety (35.4 vs. 6.3%) and clinical depression (29.2 vs. 4.2%) were also more common in patients with CTS compared with controls. All the patients with CTS exhibited MSP, whereas none of the controls reported any MSP. Anxiety was significantly and inversely associated with vitamin D levels (r²=-0.482; P<0.01), total daily calcium intake (r²=-0.294: P<0.05), and positively associated with body mass index (BMI; r²=0.200; P≤0.05) and depression (r²=0.587; P<0.01). Depression was significantly and inversely associated with vitamin D levels (r²=-0.269; P<0.01) and total daily calcium intake (r²=-0.236; P<0.05). Logistic regression analysis showed that with every unit increase in serum vitamin D levels, the odds of CTS were decreased 1.22x. While a one-unit increase in anxiety total score was associated with a 14% increase in the odds of having CTS after adjusting for different confounders. In conclusion, vitamin D deficiency, MSP and psychological symptoms are common in patients with CTS. Serum vitamin D levels and anxiety were significant independent predictors of CTS. Based on the results of the present study, it was shown that housewives had an equivalent chance of suffering from CTS morbidity as other high-risk professions. Further studies are required to confirm if vitamin D supplementation could prevent the onset of CTS.

Efficacy of platelet-rich plasma injection in mild and moderate carpal tunnel syndrome: randomized control study

Background

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. Typical symptoms and signs include numbness, tingling, pain, or burning sensation in the digits supplied by the median nerve and/or nocturnal paresthesia. Treatments of CTS range from conservative measures to surgical decompression of the median nerve.

Results

The PRP group showed a statistically significant reduction in the visual analog scale, Boston Carpal Tunnel Syndrome Questionnaire, for the severity and the functional capacity scores, and cross-sectional area of the median nerve compared to those of control group 3 months post-treatment (p < 0.05).

Conclusions

Platelet-rich plasma injection in CTS relieves pain and symptom severity and improves functional status but not significantly improve the electrophysiological parameters.

Value of ultrasonography in the diagnosis of carpal tunnel syndrome-a new ultrasonographic index in carpal tunnel syndrome diagnosis: A clinical study

We analyze the effectiveness of ultrasonography in diagnosing carpal tunnel syndrome (CTS) and propose the use of sonographic index of median nerve (MN) in carpal tunnel (SIMNCT) in a diagnostic algorithm and in establishing a scale of severity.We studied a group of 344 patients with CTS symptoms, examining them by ultrasound. We measured in all patients, on the affected hand: the size of the cross-sectional area of the MN at carpal tunnel (CT) inlet and outlet, nerve morphology at passage through CT, the vertical thickness of the MN entering into the CT - G1, the lowest vertical thickness into the CT or leaving the CT - G2, the thickness of the MN in the transversal plane as entering in the CT - L. Normal values were considered the similar measurements taken on the healthy hand and we established as normal SIMNCT = 16%. We proposed the formula SIMNCT = 100% (1-G2/G1) in order to calculate the index.Statistics show a significant sensitivity of SIMNCT (P < .0001) compared with cross-sectional area (CSA) and flattening ratio in the diagnosis of CTS. Analyzing the SIMNCT developed by us, we demonstrated a sensitivity of 94.81% and a specificity of 99.66% in CTS diagnosis. Thereby, we propose a CTS severity classification: normal = 16%, mild = 16-19%, moderate = 19% to 28%, severe = 28% to 50%, very severe > 50%.Ultrasonography is an effective method of studying the morphology of the tunnel and compressed nerve at various CTS stages and determining the cause of compression. The SIMNCT is a valuable and practical indicator and it can be used in the CTS diagnosis.

Comparison of two manual therapy techniques in patients with carpal tunnel syndrome: A randomized clinical trial

Background

Manual therapy techniques are part of physiotherapy treatment of carpal tunnel syndrome (CTS) which are classified into two groups including nerve mobilization and mechanical interface mobilization. The aim of the study was to find which manual therapy method-technique directed to mechanical interface and nerve mobilization-has superior beneficial effects on clinical and electrophysiological findings in conservative management of patients with CTS.

Methods

Thirty patients with CTS participated into two groups namely: mechanical interface and nerve mobilization in this randomized clinical trial. The intervention was performed three times weekly for 4 weeks. Mechanical interface mobilization was directed to structures around the median nerve at the forearm and wrist. Techniques of median nerve gliding and tension were used in the nerve mobilization group. The outcome measures included visual analogue scale (VAS), symptom severity scale (SSS), hand functional status scale (FSS) and motor and sensory distal latencies of median nerve. Paired t-test and ANCOVA were used for statistical analysis.

Results

At the end of the 4^th week of the treatment, the mean of VAS, SSS and FSS significantly improved in both groups (p<0.05), but the difference was not significant between the two groups (P>0.05). Although the mean of motor and sensory distal latencies of median nerve at the end of the treatment period only improved in the nerve mobilization group (p<0.05), the difference was not significant between the two groups (P>0.05).

Conclusion

Mechanical interface mobilization and nerve mobilization techniques are not superior to each other in reducing pain and improving hand symptoms and functional status.

Radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients

Background

To determine the radiographic characteristics of wrists in idiopathic carpal tunnel syndrome patients, we compared the radiographic parameters of the wrists between carpal tunnel syndrome patients and non-symptomatic controls.

Methods

We evaluated radiographic parameters of 94 wrists of 62 idiopathic carpal tunnel syndrome patients and 94 asymptomatic wrists of 94 controls. Carpal tunnel syndrome was diagnosed by clinical findings and nerve conduction studies. The lack of symptoms was confirmed with the medical records and interviews for the controls. X-ray images of the postero-anterior and lateral views of the wrist were taken. Using the obtained X-ray images, the indices of radial inclination, volar tilt, ulnar variance, and transverse and antero-posterior diameters of the wrists were measured. Two raters independently performed the measurement. One rater measured without information of clinical symptoms. Inter-rater reliabilities for each parameter were evaluated by the intra-class correlation coefficients. The averages of the measurements of two raters were compared between the carpal tunnel syndrome patients and the controls.

Results

The intra-class correlation coefficients were 0.58 for radial inclination, 0.77 for ulnar variance, 0.99 for transverse diameter, 0.60 for volar tilt, and 0.91 for antero-posterior diameter. Statistically significant correlations were found for all parameters (P < 0.01). The ulnar variance was significantly larger in the carpal tunnel syndrome patients compared to the controls (1.7 +/− 1.8 mm and 0.8 +/− 1.5 mm for the patients and controls, respectively P < 0.01). There were no significant differences in the other parameters.

Conclusions

Significant differences in the ulnar variance were observed between carpal tunnel syndrome patients and controls. This suggests that the imbalance of radioulnar bone length is one of the risk factors to develop carpal tunnel syndrome. The positive ulnar variance may be an index that needs attention to the development of carpal tunnel syndrome.

Level of evidence

level III, a case control study.

Carpal Tunnel Syndrome: A Review of Literature

Carpal tunnel syndrome (CTS) is a common medical condition that remains one of the most frequently reported forms of median nerve compression. CTS occurs when the median nerve is squeezed or compressed as it travels through the wrist. The syndrome is characterized by pain in the hand, numbness, and tingling in the distribution of the median nerve. Risk factors for CTS include obesity, monotonous wrist activity, pregnancy, genetic heredity, and rheumatoid inflammation. The diagnosis of CTS is conducted through medical assessments and electrophysiological testing, although idiopathic CTS is the most typical method of diagnosis for patients suffering from these symptoms. The pathophysiology of CTS involves a combination of mechanical trauma, increased pressure, and ischemic damage to the median nerve within the carpal tunnel. The diagnosis of CTS patients requires the respective medical professional to develop a case history associated with the characteristic signs of CTS. In addition, the doctor may question whether the patients use vibratory objects for their tasks, the parts of the arm where the sensations are felt, or if the patient may already have predisposing factors for CTS incidence. During the diagnosis of CTS, it is essential to note that other conditions may also provide similar symptoms to CTS, thus requiring vigorous diagnosis to assert the medical condition of the patients. Doctors use both non-surgical and surgical treatments when addressing CTS. Non-surgical treatments include wrist splinting, change of working position, medications, and the use of alternative non-vibrating equipment at work. On the other hand, surgical methods include open release and endoscopic surgeries. This review of literature has provided an overview of CTS with an emphasis on anatomy, epidemiology, risk factors, pathophysiology, stages of CTS, diagnosis, and management options.