Psychological factors are associated with pain extent in patients with carpal tunnel syndrome

INTRODUCTION

Widespread pain may be related to psychosocial aspects in several musculoskeletal conditions, but the literature on carpal tunnel syndrome (CTS) is scarce.

OBJECTIVE

To determine the relationship between pain extent and psychological factors (catastrophizing, kinesiophobia, anxiety symptoms, and depression) in people with CTS.

METHODS

A cross-sectional study was conducted. The independent variables were: pain intensity, disability (QuickDASH), duration of symptoms, anxiety and depressive symptoms, catastrophizing, and kinesiophobia. The main outcome was: pain extent (% of total area and categories "pain within the median nerve-innervated territory" versus "extra-median nerve pain"). Correlation analysis was performed using Spearman's correlation coefficient. A linear regression model and binary logistic regression (both with forward selection) were performed to determine the main predictors of pain extent.

RESULTS

Forty-eight participants were included. A moderate positive correlation was found between catastrophizing (r = 0.455; p = 0.024) and disability (r = 0.448; p = 0.024) with total pain extent area. Regression models indicated that catastrophizing explained 22% of the variance in the pain extent (β = 0.003; 95% CI: 0.002-0.005), while kinesiophobia was the variable that best explained the distribution of pain in the extra-median territory (R2 Nagelkerke = 0.182). Null or weak correlations were found for the rest of the associations.

CONCLUSION

Catastrophizing and kinesiophobia were the main indicators of pain extent in people with CTS. Clinicians are advised to use specific questionnaires to check for the presence of catastrophizing or kinesiophobia in people with CTS and wider pain extension.

Intraosseous Nontraumatic Median Nerve Entrapment at the Elbow: A Case Report

Intraosseous median nerve entrapment at the level of the elbow can occur after a traumatic event such as fracture and/or dislocation of the elbow. It is considered a rare and severe entity. We present a rare case of nontraumatic median nerve entrapment inside the distal humerus. No article about atraumatic intraosseous entrapment was encountered in literature.

Ultrasonographic Measurement of Median Nerve Cross-Sectional Area in Evaluating Carpal Tunnel Release Outcomes

PURPOSE

Earlier research has explored carpal tunnel release (CTR) surgery outcomes using electrodiagnostic tests (EDX). However, evaluation of the median nerve before and after CTR by ultrasound (US) is understudied. This study aimed to establish the outcomes of CTR by EDX and US, and examine the correlation between the clinical improvement and US after CTR.

METHODS

The sample consisted of 172 wrists that underwent CTR. Pain was assessed using the visual analog scale (VAS). The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), including the symptom severity and function subscales, was applied before and 3 months after CTR. The proximal and distal cross-sectional areas (CSAs) of the median nerve were measured using US, and EDX was performed before and 3 months after CTR.

RESULTS

Patients had mean preoperative and postoperative VAS scores of 7.7 ± 1.2 and 1.7 ± 1.2, respectively. The mean preoperative and postoperative proximal CSA measurements were 16.4 ± 4.5 mm2 and 12.1 ± 3.9 mm2, respectively. The mean preoperative and postoperative distal CSA measurements were 13.6 ± 3.7 mm2 and 11.0 ± 3.1 mm2, respectively. A significant improvement was observed in VAS, BCTQ, and EDX 3 months after CTR. A weak, positive correlation was observed between the improvement in the BCTQ symptom severity and function subscales and CSAs following CTR.

CONCLUSIONS

The results of this study demonstrate that preoperative median nerve CSA values may be used in evaluating CTR outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Ultrasound-guided median nerve hydrodissection of pronator teres syndrome: a case report and a literature review

Aim of the study

To describe the sonographic appearance of pronator teres syndrome and the role of ultrasound-guided hydrodissection for its management.

Case description

Pronator teres syndrome is a well-known compressive neuropathy of the median nerve between the two heads of pronator teres. However, the clinical presentation of this syndrome can be indolent with vague pain at the proximal volar forearm leading to a delay in diagnosis. We describe our experience in the management of pronator teres syndrome in a healthy young badminton player with ultrasound-guided median nerve hydrodissection. We highlight the clinical presentation, the role of dynamic Ultrasound scan (USS) in the diagnosis and effective treatment of pronator teres syndrome.

Conclusions

In conclusion, managing PTS can be challenging, and this case highlights the importance of ultrasound-guided hydrodissection, when conservative measures have failed to improve the symptoms. Further studies are required to assess and compare the long-term outcomes of these interventions.

Transscaphoid Transcapitate Perilunate Fracture-dislocation with Inferior Arc Injury and Acute Ulnar Nerve Compression: A Case Report

Introduction

Perilunate dislocations and perilunate fracture-dislocations (PLFD) are relatively uncommon injuries, comprising <10% of wrist injuries. Perilunate injuries are often complicated by median neuropathy reported in 23-45% of cases, whereas there are very few reported cases of associated ulnar neuropathy. Combined greater arc and inferior arc injuries are also rare. We report an unusual PLFD pattern with associated inferior arc injury and acute ulnar nerve compression.

Case Report

A 34-year-old male sustained a wrist injury after a motorcycle collision. Computed tomography scan revealed a trans-scaphoid, transcapitate, perilunate fracture-dislocation, and a distal radius lunate facet volar rim fracture with radiocarpal subluxation. Examination revealed acute ulnar neuropathy without median neuropathy. He underwent urgent nerve decompression and closed reduction, followed by open reduction internal fixation the next day. He recovered without complication.

Conclusion

This case emphasizes the importance of a thorough neurovascular examination to rule out less commonly seen neuropathies. With up to 25% of perilunate injuries misdiagnosed, surgeons should have a low threshold for advanced imaging in high-energy injuries.

Open Carpal Tunnel Release With a Z-plasty Rearrangement for Median Nerve Mononeuropathy Secondary to Traumatic Scar Contracture

We present the case of a 56-year-old woman who developed carpal tunnel syndrome and palmar scar contracture secondary to a left-hand palmar laceration in a pedestrian versus motor vehicle accident. The patient underwent carpal tunnel release and a Z-plasty rearrangement to restore normal thumb movement. The patient reported significant improvement in thumb mobility, resolution of median neuropathy symptoms, and no pain along the scar at her three-month follow-up. Our case illustrates the effectiveness of a Z-plasty in relieving tension along scars and potential management for traction-type extraneural neuropathy arising from scar contracture.

Evaluation of Sympathetic Vasomotor Activity of the Brachial Arteries Using Doppler Ultrasound

BACKGROUND The sympathetic nervous system is principally accountable for peripheral artery regulation, and its effect is that vasospasm occurs in the medium and large arteries of the extremities, resulting in decreased flow of blood. Because of this information of how the body works, our goal is to create a noninvasive and repeatable self-test model that uses Doppler ultrasound examination. MATERIAL AND METHODS The study was conducted on 31 healthy and active participants who volunteered for the study. Written informed consent was obtained from all participants. The baseline diameter and flow rates of the brachial artery from 2 cm superior to the antecubital fossa were determined using a Doppler probe, which remained stationary throughout the experiment, allowing for continuous measurements. Then, to activate the sympathetic fibers, an electrical stimulus was applied for 5 s with an intensity of 10 mA and frequency of 1 Hz at the level of the median nerve at the wrist via the bipolar stimulation electrode. Immediately following the sixth stimulation, the artery diameter and flow rates were assessed again. RESULTS Following the stimulation, a statistically significant decrease in flow rate was observed (P<0.001). Moreover, stimulation resulted in a statistically significant reduction in the diameter of the brachial artery (P<0.001). CONCLUSIONS Our research suggests that Doppler ultrasonography can be routinely used to detect the normal and abnormal functioning of the peripheral sympathetic nervous system.

Fibrolipomatous hamartoma of the median nerve: An unusual cause of carpal tunnel syndrome

Fibrolipomatous hamartoma is a rare benign tumor-like condition that affects most commonly the median nerve. The diagnosis is usually confirmed through its typical appearance on magnetic resonance imaging (MRI) without the need for a nerve biopsy. There are divergent views regarding treatment of this entity, but open carpal tunnel release for nerve decompression currently constitutes the standard care for alleviation of compressive neuropathy of the median nerve. In this report, we describe a case of fibrolipomatous hamartoma that was diagnosed via MRI and underwent open carpal tunnel release, with alleviation of the patient's symptoms.

Clinical and electrophysiological efficacy of extracorporeal shock-wave therapy in carpal tunnel syndrome: a placebo-controlled, double-blind clinical trial

OBJECTIVE

The aim of this study was to evaluate the efficacy of radial extracorporeal shock wave therapy on pain, functionality, and electrophysiological measurements in carpal tunnel syndrome.

METHODS

Between June 2021 and January 2022, a total of 66 wrists in 45 participants with mild-to-moderate carpal tunnel syndrome were included in this double-blind, prospective, randomized, placebo-controlled study. Patients were randomized into two groups, namely, the radial extracorporeal shock wave therapy (group 1, n=33) and the sham radial extracorporeal shock wave therapy (group 2, n=33). Night splints and tendon nerve gliding exercises were given to all participants. The participants were evaluated at baseline and the first month after treatment. Participants were evaluated using a visual analog scale, the Boston Carpal Tunnel Questionnaire, Leeds Neuropathic Symptom and Symptom Assessment, and electrophysiological examinations.

RESULTS

A total of 37 participants (a total of 55 wrists, radial extracorporeal shock wave therapy n=27, and sham radial extracorporeal shock wave therapy n=28) completed the study. After the intervention, there was a significant decrease in visual analog scale values (p<0.001) and a significant increase in Boston Carpal Tunnel Questionnaire scores (p<0.001) and Leeds Neuropathic Symptom and Symptom Assessment scores (p<0.001). In electrophysiological measurements, there was a significant decrease in median nerve sensory (p=0.002) and motor (p=0.003) distal latency, and a significant increase in median nerve sensory conduction velocity (p=0.026) was found in the radial extracorporeal shock wave therapy group.

CONCLUSION

This study shows that radial extracorporeal shock wave therapy has positive effects on pain, functionality, and electrophysiological measurements for mild-to-moderate carpal tunnel syndrome 1 month after application.

Prevalence and Predictors of Carpal Tunnel Syndrome Symptoms Among Teachers in Riyadh: A Cross-Sectional Study

Background Carpal tunnel syndrome (CTS) is a musculoskeletal disorder (MSD) afflicting the upper limbs with a prevalence of approximately 14.4% in the general population. Previous studies have noted the increasing prevalence of MSDs among teachers but have not investigated in depth the prevalence and predictors of CTS symptoms in this population. The aim of this study was to help fill this gap in the literature by investigating teachers working in Riyadh, Saudi Arabia. Methods We conducted this cross-sectional study in Riyadh using an online survey. We distributed the Boston carpal tunnel questionnaire (BCTQ) to schoolteachers in the city through the social media applications Twitter, WhatsApp, and Telegram. We assessed the respondents' symptoms using Univariate association analyses with a Wilcoxon rank sum test for the continuous variables and Fisher's exact test and Pearson's chi-squared test for the categorical variables. We assessed the independent risk factors for CTS by constructing multivariate binary logistic regression models and expressed the results using the odds ratio (OR) and 95% confidence intervals (95% CIs), with p < 0.05 indicating statistical significance. Results The sample for this study included 490 teachers. Among them, the prevalence of moderate to severe CTS symptoms was 40.0%, and self-reported CTS was 9.1%. The teachers who were female, relatively old, left-handed, retired, and spent significant time using a pen, keyboard, and/or blackboard were more likely than those who were male, relatively young, right-handed, and did not spend significant time using a pen, keyboard, and/or blackboard to self-report CTS and exhibit moderate to severe symptoms. Conclusions We found a relatively high percentage (40.0%) of CTS symptoms among teachers working in Riyadh. This finding suggests that any sign of CTS symptoms should be checked to ensure early diagnosis and treatment, which contribute to positive outcomes, particularly given the recent increase in such risk factors for CTS as diabetes, hypothyroidism, and high BMI in populations worldwide.

Revision Carpal Tunnel Release With Umbilical Cord Allograft: A Four-Year Retrospective Cohort Study

Background: Refractory symptoms of carpal tunnel syndrome can persist or reoccur after carpal tunnel release (CTR) surgery in 1% to 25% of patients, with up to 12% of patients requiring secondary surgery. If revision surgery is required, the results are much less successful compared to primary surgery. In this study, we investigated whether cryopreserved human umbilical cord allograft placement during CTR revision surgery improved short- and long-term surgical outcomes. Methods: We conducted a single-center cohort analysis of patients between January 2015 and July 2018 who underwent secondary open revision CTR with umbilical cord allograft for recurrent or persistent compression neuropathy of the median nerve. Surgical outcomes of patients in the study group-reduction of pain, paresthesia, and weakness; complications; and Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores-were compared to the outcomes of controls without umbilical cord allograft use who were operated on by the same surgeon between December 2011 and September 2015. Results: A total of 37 patients underwent CTR with (n=26) and without (n=11) umbilical cord allograft (mean follow-up of 4 years). Following surgery, preoperative symptoms of pain (96% vs 73%, P=0.048) and paresthesia (100% vs 73%, P=0.014) were significantly improved in the patients who received umbilical cord allograft. Mean QuickDASH scores (19.0 vs 23.7, P=0.58) and preoperative weakness (90% vs 67%, P=0.14) were improved in the patients who received umbilical cord allograft but were nonsignificant. Short- and long-term complications were similar between groups (P=0.56, P=0.51, respectively). Conclusion: This study suggests that human umbilical cord allograft placement during open revision CTR is safe and effective for improving long-term symptoms of compressive neuropathy in patients with recurrent carpal tunnel syndrome.

Median nerve entrapments in the forearm - a case report of rare anterior interosseous nerve syndrome

Nowadays, median nerve entrapment is a frequent issue. Many physicians are familiar with the most common median entrapment, which is the carpal tunnel syndrome (CTS). By contrast, less frequent entrapments, historically called "pronator syndrome" are still misdiagnosed as overuse syndrome, flexor tendinitis or other conditions. This article is meant to introduce proximal median nerve entrapments, followed by a case report of the rarest example - anterior interosseous nerve syndrome (AIN syndrome).

Is Smoking Associated with Carpal Tunnel Syndrome? A Meta-Analysis

To date, the role of smoking in carpal tunnel syndrome (CTS) is unclear. The aim of this systematic review and meta-analysis was to assess the association between smoking and CTS. The literature searches were conducted in PubMed, Embase, and Scopus, from inception until October 2021. Three reviewers screened the titles, abstracts, and full-text articles and evaluated the methodological quality of the included studies. A random-effects meta-analysis was used, and heterogeneity across studies was examined using I² statistic. A total of 31 (13 cross-sectional, 10 case-control, and 8 cohort) studies were qualified for meta-analysis. In a meta-analysis of cohort studies, the risk of CTS did not differ between current and never smokers (pooled hazard ratio (HR) 1.09, 95% CI 0.84–1.43), current and past/never smokers (HR 1.07, 95% CI 0.94–1.23), and past and never smokers (HR 1.12, 95% CI 0.83–1.49). Furthermore, a meta-analysis of case control studies found no difference in the risk of CTS between current and never smokers (pooled odds ratio (OR) 0.92, 95% CI 0.56–1.53), current and past/never smokers (OR 1.10, 95% CI 0.51–2.36), and past and never smokers (OR 0.91, 95% CI 0.59–1.39). However, a meta-analysis of cross-sectional studies showed the associations of ever (OR 1.36, 95% CI 1.08–1.72) and current smoking (OR 1.52, 95% CI 1.11–2.09) with CTS. However, the association between ever smoking and CTS disappeared after limiting the meta-analysis to higher quality studies or after adjusting for publication bias. The association between current smoking and CTS also attenuated after limiting the meta-analysis to studies that confirmed CTS by a nerve conduction study or studies with low attrition bias. This meta-analysis does not support an association between smoking and CTS. The association between smoking and CTS observed in cross-sectional studies could be due to biases and/or confounding factors.

Rare Tumors Causing Median Nerve Compression in Adults-A Narrative Review

The median nerve can be compressed due to a tumor along the course of the median nerve, causing typical compression symptoms or even persistence or recurrence after an operation. The aim of this review is to provide a comprehensive overview of rare tumors described in recent publications that cause median nerve compression and to evaluate treatment options. The PubMed, Embase, and Web of Science databases were searched for studies describing median nerve compression due to a tumor in adults, published from the year 2000 and written in English. From 94 studies, information of approximately 100 patients have been obtained. Results  The rare tumors causing compression were in 32 patients located at the carpal tunnel, in 21 cases in the palm of the hand, and 28 proximal from the carpal tunnel. In the other cases the compression site extended over a longer trajectory. There were 37 different histological types of lesions. Complete resection of the tumor was possible in 58 cases. A total of 8 patients presented for the second time after receiving initial therapy. During follow-up, three cases of recurrence were reported with a mean follow-up period of 11 months. The most common published cause of median nerve compression is the lipofibromatous hamartoma. Besides the typical sensory and motor symptoms of median nerve compression, a thorough physical examination of the complete upper extremity is necessary to find any swelling or triggering that might raise suspicion of the presence of a tumor.

Proximal Median Nerve Compression in the Differential Diagnosis of Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common median nerve compression neuropathy. Its symptoms and clinical presentation are well known. However, symptoms at median nerve distribution can also be caused by a proximal problem. Pronator syndrome (PS) and anterior interosseous nerve syndrome (AINS) with their typical characteristics have been thought to explain proximal median nerve problems. Still, the literature on proximal median nerve compressions (PMNCs) is conflicting, making this classic split too simple. This review clarifies that PMNCs should be understood as a spectrum of mild to severe nerve lesions along a branching median nerve, thus causing variable symptoms. Clear objective findings are not always present, and therefore, diagnosis should be based on a more thorough understanding of anatomy and clinical testing. Treatment should be planned according to each patient's individual situation. To emphasize the complexity of causes and symptoms, PMNC should be named proximal median nerve syndrome.

Intraosseous Type 2 Median Nerve Entrapment After Posterior Elbow Dislocation Diagnosed on Ultrasound With MRI and Surgical Correlation

Median nerve entrapment is a rare complication of posterior elbow dislocation and medial epicondyle fracture. In the event of delayed diagnosis, this injury pattern may result in significant and sometimes irreversible nerve damage. As such, a high degree of clinical suspicion and early imaging is indicated in patients with persistent nerve deficits following reduction of elbow dislocation.

Here, a case of intraosseous type 2 median nerve entrapment that was diagnosed on ultrasound in an eight-year-old patient following ulnohumeral dislocation is discussed. This article reviews the key imaging findings of median nerve entrapment and discusses the subsequent MRI and surgical findings of this rare condition.

Systematic review and meta-analysis of surgical options for recurrent or persistent carpal tunnel syndrome: simple decompression versus coverage of the median nerve

We performed a systematic review on the success of different surgical techniques for the management of recurrent and persistent carpal tunnel syndrome. Twenty studies met the inclusion criteria and were grouped by the type of revision carpal tunnel release, which were simple open release, open release with flap coverage or open release with implant coverage. Meta-analysis showed no difference, and pooled success proportions were 0.89, 0.89 and 0.85 for simple open carpal tunnel release, additional flap coverage and implant groups, respectively. No added value for coverage of the nerve was seen. Our review indicates that simple carpal tunnel release without additional coverage of the median nerve seems preferable as it is less invasive and without additional donor site morbidity. We found that the included studies were of low quality with moderate risk of bias and did not differentiate between persistent and recurrent carpal tunnel syndrome.

Electrodiagnostic Studies in the Surgical Treatment of Carpal Tunnel Syndrome-A Systematic Review

The aim of our paper was to provide comprehensive data on the role of electrodiagnostic (EDX) studies in the surgical treatment of carpal tunnel syndrome (CTS). An extensive search was conducted through the major electronic database to identify eligible articles. Data extracted included grade of CTS based on neurophysiological testing, preoperative data of EDX studies, time of complete or partial resolution after surgery, postoperative Boston carpal tunnel questionnaire (CTQ) scores, age, sex, intraoperative and postoperative data of EDX studies, time to complete or partial resolution of symptoms, and number of patients without postsurgical improvement. Our main findings revealed that that electrodiagnostic testing is still a powerful tool for diagnosis of CTS. Moreover, it can also detect other pathologies. EDX testing provides a quantitative measure of the physiological function of the median nerve, which may be used to guide surgical treatment. Thirdly, when the outcome of surgery is unsatisfactory, NCS can assist in determining the reason for failure.

Is there an association between the Hand Diagram and Electrodiagnostic Testing for Carpal Tunnel Syndrome?

Objective  Verify if there is an association between the hand diagram of paresthesia (HDP) and the results of electroneuromyography (ENMG) in the diagnosis of carpal tunnel syndrome.

Methods  A total of 92 people filled in a schematic drawing of the hand with the exact location of the paresthesia (167 hands). The main author classified the diagrams according to the criteria of Katz et al. 5 The results of the HDP were crossed with the positive results of ENMG for the diagnosis of carpal tunnel syndrome.

Results  The possible pattern of the HDP was prevalent both in isolation and after crossing with the degrees of ENMG.

Conclusion  There was no association between the HDP and ENMG in the diagnosis of carpal tunnel syndrome.

Electrodiagnostic Testing Characteristics of Diabetic People with Carpal Tunnel Syndrome

Objective  The present study aimed to correlate electroneuromyography (ENMG) findings in diabetic and nondiabetic subjects with carpal tunnel syndrome (CTS).

Methods  In total, 154 patients were evaluated in a hand surgery outpatient clinic. All ENMG tests were bilaterally performed by a single neurologist. Qualitative variables were described for all patients with CTS according to their diabetic status, and the chi-squared test was used to reveal any association. A joint model was adjusted to determine the influence of diabetes on ENMG severity in CTS patients.

Results  The sample consisted of 117 women and 37 men, with an average age of 56.9 years old. Electroneuromyography demonstrated bilateral CTS in 82.5% of the patients. Diabetes was identified in 21.4% of the cases. Severe ENMG was prevalent.

Conclusion  There was no association between diabetes and ENMG severity in patients with CTS. Level of evidence IV, case series.

Shoulder Double Crush Syndrome: A Retrospective Study of Patients With Concomitant Suprascapular Neuropathy and Cervical Radiculopathy

Purpose

While the double crush phenomena (compression along two points on a nerve) has been established between median neuropathy and cervical radiculopathy, combined suprascapular neuropathy (SSN) and cervical C5/C6 radiculopathy-so-called shoulder double crush syndrome-has not been well examined. We aim to identify the incidence of shoulder double crush syndrome in patients undergoing arthroscopic suprascapular nerve release for SSN.

Methods

One hundred consecutive patients >18 years of age who were positive for SSN on electromyography and motor nerve conduction studies (EMG/NCS) and underwent a suprascapular nerve release were included. Patients with evidence of shoulder double crush syndrome were identified based on x ray, cervical spine magnetic resonance imaging (MRI) and examination findings. Demographics, electrodiagnostics results, treatment courses, and clinical outcomes (visual analog scores and rotator cuff strength) following arthroscopic suprascapular nerve release were compared between patients with double crush syndrome versus isolated SSN.

Results

Thirty one percent of patients had evidence of shoulder crush syndrome. Two significant electrophysiologic differences were noted in shoulder double crush patients compared to isolated SSN patients. Patients with double crush had an increased incidence of median neuropathy (51% vs 30%, P = .04). Double crush patients had less supraspinatus motor amplitude difference between the affected side and non-affected side compared to isolated SSN patients (2.62 mV vs 3.44 mV, P = .03). In general, most double crush patients were treated conservatively with regard to their cervical spine pathology.

Conclusion

A significant percentage of patients with SSN have evidence of shoulder double crush syndrome. Patients with SSN and concomitant median neuropathy should have a detailed neck examination performed.

Value of Grayscale and Power Doppler High-Resolution Ultrasound in Assessment of Patients with Clinically Suspected Carpal Tunnel Syndrome

OBJECTIVES

To determine the value of grayscale and power Doppler ultrasound (PDUS) in the evaluation of carpal tunnel syndrome (CTS) in clinically suspected patients.

METHODS

Eighty-seven wrists of 61 patients with clinically suspected CTS and 57 wrists of 30 healthy control participants were included in our study. Median nerve (MN) cross-sectional area (CSA) measurements were performed at the tunnel inlet level (wCSA) and proximal pronator quadratus muscle level (fCSA). Two parameters were calculated: CSA absolute difference (ΔCSA), which was the difference between the two measurements; and CSA ratio (RCSA), calculated by dividing wCSA over fCSA. The MN at the wrist level was evaluated for hypervascularity with PDUS.

RESULTS

The mean wCSA, R-CSA, and ΔCSA values were significantly higher in patients (17 mm² , 2.45, and 9.9 mm² , respectively) than in control participants (8 mm² , 1.29, and 1.65 mm² ; (P < .0001). At their corresponding cutoff values, the wCSA yielded higher sensitivity (95%) and lower specificity (88%) compared to the RCSA and ΔCSA (89% and 93% sensitivity and 93% and 89% specificity). Power Doppler US was the most specific US parameter (100%) but the least sensitive (76%). A multivariate logistic regression model including the wCSA, RCSA, and PDUS yielded 97% diagnostic accuracy at their optimal cutoffs, which increased to 99% after eliminating age and body mass index confounding effects.

CONCLUSIONS

The combination of MN swelling measurements and PDUS increases the diagnostic accuracy of US in patients with clinically suspected CTS.

'INSIGHT-PRECISION': a new, mini-invasive technique for the surgical treatment of carpal tunnel syndrome

Objective

To describe a new mini-invasive surgical technique for carpal tunnel release and to present clinical findings associated with using this technique.

Methods

Patients with idiopathic carpal tunnel syndrome without prior surgical treatment, who underwent a new minimally-invasive surgical technique using a specific surgical tool-kit developed by the author, were included. Prospective data were collected, including preoperative electrodiagnostic testing. The subjective condition of all patients was evaluated pre- and postoperatively with a five-level Likert-type scale (LS) and muscular strength was tested using a JAMAR dynamometer and pinch gauge.

Results

A total of 116 patients (157 hands/cases) underwent surgery performed by the author, and were followed for a mean of 40 months (range, 6 months–7 years). Of these, preoperative electrodiagnostic testing was performed in 112 patients (96.6%). No significant complications were reported. By three months, patients reported that they were satisfied or very satisfied in 147/149 cases (98.7%; LS grade I and II). Strength recovery at three months, based on the average of four measures, was 99.17% (range, 97.43–100.97%).

Conclusions

The described technique is minimally invasive, safe and simple to perform, and provides good results.

Effect of extracorporeal shockwave therapy on carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although several trials have reported the use of extracorporeal shock wave therapy (ESWT) for mild to moderate carpal tunnel syndrome (CTS), little is known about the efficacy of ESWT. Thus, we performed a meta-analysis to evaluate whether ESWT can improve symptoms, functional outcomes, and electrophysiologic parameters in CTS.

METHODS

Six randomized controlled trials investigating the effect of ESWT on CTS were retrieved from PubMed, Embase, and the Cochrane Library. We performed a pairwise meta-analysis using fixed- or random-effects models.

RESULTS

ESWT showed significant overall effect size compared to the control (overall Hedge g pooled standardized mean difference (SMD) = 1.447; 95% confidence interval [CI], 0.439-2.456; P = .005). Symptoms, functional outcomes, and electrophysiologic parameters all improved with ESWT treatment. However, there was no obvious difference between the efficacy of ESWT and local corticosteroid injection (pooled SMD = 0.418; 95% CI, -0.131 to 0.968; P = .135). A publication bias was not evident in this study.

CONCLUSION

Our meta-analysis revealed that ESWT can improve symptoms, functional outcomes, and electrophysiologic parameters in patients with CTS. Further research is needed to confirm the long-term effects and the optimal ESWT protocol for CTS.

Effects of Median Nerve Neural Mobilization in Treating Cervicobrachial Pain: A Randomized Waiting List-Controlled Clinical Trial

BACKGROUND

There is a current lack of sufficiently high-quality randomized controlled clinical trials that measure the effectiveness of neural tissue mobilization techniques such as median nerve neural mobilization (MNNM) and their specific effects on cervicobrachial pain (CP). The aim of this study was to compare the effectiveness of MNNM in subjects with CP vs. a waiting list control group (WLCG).

METHODS

A single-blinded, parallel, randomized controlled clinical trial was performed (NCT02596815). Subjects were recruited with a medical diagnosis of CP corroborated by magnetic resonance imaging. In total, 156 individuals were screened, 60 subjects were recruited, and 51 completed the trial. Pain intensity reported using the Numeric Rating Scale for Pain (NRSP; primary outcome), cervical range of motion (CROM), and functionality using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scale were the outcome measurements. Assessments were conducted at baseline and 1 hour after treatment (intervention days 1, 15, and 30). Therefore, MNNM was implemented with 30 days of follow-up.

RESULTS

The NRSP values of the MNNM group were significantly (P < 0.0001; 95% confidence interval [CI]) superior to those obtained in the WLCG. Subjects treated with MNNM reported an NRSP decrease of 3.08 points at discharge. CROM and QuickDASH outcome values were significantly (P ˂ 0.0001; 95% CI) improved only in the MNNM group. Hedges' g showed a very large effect of the MNNM intervention.

CONCLUSION

MNNM may be superior to no treatment in reducing pain and increasing function in the affected upper limbs of subjects with CP.

Lumbrical-interosseous recording technique versus routine electrodiagnostic methods in the diagnosis of carpal tunnel syndrome

Objectives

We aimed to evaluate the sensitivity of second lumbrical-interosseous (L-I) technique and to compare the results with other electrophysiological methods in patients with carpal tunnel syndrome (CTS).

Patients and methods

This cross-sectional study was conducted in an electrophysiology laboratory of a university hospital between January 2003 and January 2004. A total of 102 patients with CTS (174 hands) and 40 healthy controls (80 hands) were included. Median motor nerve conduction studies were obtained with recordings from the abductor pollicis brevis (APB), median sensory nerve conduction studies from digits I-III and at palm-wrist segment (P-W), median-ulnar sensory comparison at digit IV (M-U), and median-radial sensory comparison at digit I (M-R) were along with L-I technique.

Results

The highest sensitivities were found in the median sensory conduction velocity across the palm-wrist (88%), and digit I-wrist segments (80%), median motor distal latency over the APB (77%), and L-I study (76%). The specificities of conventional tests were higher than the sensitivity of L-I method (63%).

Conclusion

L-I method has a good diagnostic sensitivity in CTS; however, P-W, median sensory nerve conduction velocity at digit I and median distal motor latency are more sensitive than L-I method. Therefore, L-I method can be applied as a supportive technique in the evaluation of patients with CTS.

Amyloid detection in the transverse carpal ligament of patients with hereditary ATTR V30M amyloidosis and carpal tunnel syndrome

INTRODUCTION

Carpal tunnel syndrome (CTS) is a nonspecific manifestation of hereditary ATTR amyloidosis (ATTRm). Amyloid deposition of wild-type TTR (WT-ATTR) has been found in transverse carpal ligament (TCL) in idiopathic CTS. We retrospectively studied a group of patients with ATTRm and CTS submitted to carpal tunnel release surgery (CTRS).

METHODS

From the nerve conduction studies performed in our Clinical Unit dedicated to hereditary amyloidosis between July 2009 and October 2013, we selected patients who fulfilled neurophysiological criteria for CTS, had been submitted to CTRS and whose TCL was available for pathology. Clinical registries were reviewed and amyloid detection in the ligaments was performed using Congo-red staining.

RESULTS

We included 16 patients: three males (18.8%), mean age = 46.1 years old, all with V30M mutation. At the time of surgery, four patients were considered asymptomatic and 12 symptomatic carriers, five of them late-onset ATTRm (onset age >50 years old). In all but one patient, the CTS preceded the polyneuropathy. Amyloid detection in the TCL was positive in 14 patients (87.5%).

DISCUSSION/CONCLUSIONS

In most patients, CTS preceded or was contemporary to the polyneuropathy and amyloid detection in TCL was positive. The detection of amyloid in TCL may add specificity to CTS as an early manifestation of the disease but more studies are needed.

Quality of Care for Work-Associated Carpal Tunnel Syndrome

OBJECTIVE

To evaluate the quality of care provided to individuals with workers' compensation claims related to Carpal tunnel syndrome (CTS) and identify patient characteristics associated with receiving better care.

METHODS

We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects' medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality.

RESULTS

Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, sex, and race/ethnicity were not associated with quality.

CONCLUSIONS

Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones.

Mixed neuropathy presenting clinically as an anterior interosseous nerve palsy following shoulder arthroscopy: a report of four cases

BACKGROUND

Anterior interosseous nerve (AIN) palsies can arise spontaneously or be attributed to one of many causes. We present 4 cases, the largest series to date, in which a mixed peripheral neuropathy presented primarily as an AIN palsy following ipsilateral shoulder arthroscopy. In this report, we detail the patient's presenting symptoms, describe our management of the complication, and provide hypotheses for the mechanism behind the complication.

METHODS

Four different surgeons performed the initial arthroscopic surgeries, but the senior author in all cases managed follow-up and treatment of the neuropathy. All patients were informed and agreed to have their cases published.

RESULTS

All four patients experienced significant recovery, although 2 of 4 required AIN decompression and exploration because of failure to improve with conservative management.

CONCLUSION

Whereas variables such as position, index surgical procedure, and use of regional anesthesia varied among our patients, the one constant was the fluid extravasation from the arthroscopy itself, and for this reason we believe that if there is one singular cause to explain all of these neuropathies, it would be increased pressure in the upper arm and forearm from fluid extravasation in patients with at-risk anatomy. Outside of prevention, recognizing this complication and providing appropriate intervention or referral to a surgeon capable of appropriate intervention are important for any surgeon performing shoulder arthroscopies.

Median nerve penetration by a persistent median artery and vein mimicking carpal tunnel syndrome

INTRODUCTION

Carpal tunnel syndrome (CTS) is a common clinical syndrome seen in the outpatient setting that is easily confirmed by electrodiagnostic testing.

METHODS

We describe the case of a patient who presented with the classic symptoms and neurological examination for CTS, but had a normal nerve conduction study and electromyogram.

RESULTS

Neuromuscular ultrasound of the median nerve on the symptomatic side revealed penetration of the nerve by a persistent median artery and vein in the mid-forearm, with a positive sonographic Tinel sign over this spot. This finding is an anatomical variation that has been described sparingly in the literature, mostly in cadavers. It has not been reported previously to be a mimic of CTS.

CONCLUSIONS

This case demonstrates the diagnostic utility of neuromuscular ultrasound and the importance of considering an anatomical variation involving the median nerve in the differential diagnosis of CTS.

The effect of excess body mass on the risk of carpal tunnel syndrome: a meta-analysis of 58 studies

We aimed to estimate the effects of overweight and obesity on carpal tunnel syndrome (CTS), and to assess whether sex modifies the associations. Literature searches were conducted in PubMed, Embase, Web of Science, Scopus, Google Scholar and ResearchGate databases from 1953 to February 2015. Fifty-eight studies consisting of 1,379,372 individuals qualified for a meta-analysis. We used a random-effects meta-analysis, assessed heterogeneity and publication bias, and performed sensitivity analyses. Overweight increased the risk of CTS or carpal tunnel release 1.5-fold (pooled confounder-adjusted odds ratio [OR] = 1.47, 95% CI 1.37-1.57, N = 1,279,546) and obesity twofold (adjusted OR = 2.02, 95% CI 1.92-2.13, N = 1,362,207). Each one-unit increase in body mass index increased the risk of CTS by 7.4% (adjusted OR = 1.074, 95% CI 1.071-1.077, N = 1,258,578). Overweight and obesity had stronger effects on carpal tunnel release than CTS. The associations did not differ between men and women, and they were independent of study design. Moreover, the associations were not due to bias or confounding. Excess body mass markedly increases the risk of CTS. As the prevalence of overweight and obesity is increasing globally, overweight-related CTS is expected to increase. Future studies should investigate whether a square-shaped wrist and exposure to physical workload factors potentiate the adverse effect of obesity on the median nerve.

Ultrasound findings of carpal tunnel syndrome in a Hunter syndrome patient

INTRODUCTION

Hunter syndrome (mucopolysaccharidosis II) is a rare genetic disorder. Carpal tunnel syndrome (CTS) is a common finding in these patients.

METHODS

We report the ultrasound findings in a 40-year-old Hunter syndrome patient with severe CTS.

RESULTS

Marked abnormalities of the median nerve were present proximal to the carpal tunnel with an unusual area of increased echogenicity between enlarged fascicles separating the area of maximal enlargement and the normal median nerve proximally.

CONCLUSIONS

This case demonstrated unique ultrasound findings in a Hunter syndrome with CTS. Ultrasound also localized the median nerve lesion in the setting of end-stage median neuropathy and nonlocalizing electrophysiology.

Analysis of the Papal Benediction Sign: The ulnar neuropathy of St. Peter

The origin of the Papal Benediction Sign has been a source of controversy for many generations of medical students. The question has been whether the Papal Benediction Sign posture is the result of an injury to the median nerve or to the ulnar nerve. The increasingly popular use of online "chat rooms" and the vast quantities of information available on the internet has led to an increasing level of confusion. Looking in major anatomy texts, anatomy and board review books as well as numerous internet sites the answer remains unresolved. Through the analysis of functional anatomy of the hand, cultural and religious practices of the early centuries of the Common Era and church art a clear answer emerges. It will become apparent that this hand posture results from an ulnar neuropathy.

Neurovascular compromise due to true brachial artery aneurysm at the site of a previously ligated arteriovenous fistula: Case report and review of literature

True arterial aneurysms of the upper extremity are rare. The case described is that of a 48-year-old man presenting with median neuropathy and distal vascular compromise 4 years after ligation of a brachiocephalic arteriovenous fistula. We describe our approach and present a review of the relevant literature.

Personal and workplace factors and median nerve function in a pooled study of 2396 US workers

OBJECTIVE

Evaluate associations between personal and workplace factors and median nerve conduction latency at the wrist.

METHODS

Baseline data on workplace psychosocial and physical exposures were pooled from four prospective studies of production and service workers (N = 2396). During the follow-up period, electrophysiologic measures of median nerve function were collected at regular intervals.

RESULTS

Significant adjusted associations were observed between age, body mass index, sex, peak hand force, duration of forceful hand exertions, Threshold Limit Value for Hand Activity Limit, forceful repetition rate, wrist extension, and decision latitude on median nerve latencies.

CONCLUSIONS

Occupational and nonoccupational factors have adverse effects on median nerve function. Measuring median nerve function eliminates possible reporting bias that may affect symptom-based carpal tunnel syndrome case definitions. These results suggest that previously observed associations between carpal tunnel syndrome and occupational factors are not the result of such reporting bias.

Idiopathic bilateral carpal tunnel syndrome in a 9-month-old infant presenting as a pseudo-dystonia

BACKGROUND

Carpal tunnel syndrome is the most common focal peripheral neuropathy seen in most electrophysiological laboratories. Although the incidence of carpal tunnel syndrome in adults is 50 to 150 cases per 100,000 people, it is rare in children. There are less than 200 case reports of carpal tunnel syndrome in children, with mucopolysaccharides and mucolipidosis being the most frequent cause. Idiopathic carpal tunnel syndrome with childhood onset occurs in less than 0.2% of cases.

PATIENT

We describe a 9-month-old infant who presented with intermittent abnormal posturing movement of both hands.

RESULTS

The clinical presentation and the electrophysiological studies confirmed the diagnosis of carpal tunnel syndrome. His dystonic posturing had disappeared completely 3 weeks after surgical release of both flexor retinaculi.

CONCLUSION

We are not only reporting the youngest child with carpal tunnel syndrome, but we also report a new cause of abnormal movement disorder in children.

Carpal tunnel syndrome in children

BACKGROUND

Carpal tunnel syndrome or median neuropathy at the wrist is a rare condition in children. Of the reported patients with carpal tunnel syndrome, mucopolysaccharidoses and the mucolipidoses are the most common causes.

PATIENTS

We report 13 patients between the ages of 2 and 17 years of age with carpal tunnel syndrome.

RESULTS

Mucopolysaccharidoses was the cause in one child. In other children, trauma to the median nerve, malformations of the wrist, brachial plexopathy, obesity, inherited susceptibility to pressure palsies (PMP 22 gene deletion), and family history of median neuropathy at the wrist were identified. All patients had hand pain, numbness, and paresthesias in their hands. The nerve conduction studies showed prolongation of median sensory nerve latency and distal motor latency in median nerve.

CONCLUSIONS

Carpal tunnel syndrome occurs in children and a variety of risk factors predispose to its occurrence.

An open-label pilot study evaluating the effectiveness of the heated lidocaine/tetracaine patch for the treatment of pain associated with carpal tunnel syndrome

OBJECTIVES

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy of the median nerve at the wrist that is characterized by pain, paresthesias, weakness, and loss of dexterity. This pilot study was conducted to evaluate the heated lidocaine/tetracaine patch (HLT patch) as a conservative treatment for pain of CTS.

METHODS

Twenty adult patients (mean age = 44 ± 12 years) with pain secondary to unilateral CTS and electrodiagnostic evidence of mild-to-moderate CTS enrolled in this open-label study. Patients were treated with a single HLT patch placed over the junction of forearm and wrist on the palmar aspect of the wrist twice daily (morning and evening at 12-hour intervals) for 2 hours. At baseline and during the 2-week study, patients graded their pain intensity with an 11-point numerical rating scale (0 = no pain, 10 = worst imaginable pain). Pain interference with general activity, work, and sleep was evaluated with a similar 0-to-10-point scale.

RESULTS

Fifteen patients completed the 14-day treatment period. Mean average pain intensity score decreased from 5.1 ± 1.5 at baseline to 2.5 ± 1.6 at end of study in the per-protocol population (P < 0.001). Two-thirds of the patients demonstrated clinically meaningful pain relief (≥ 30% reduction in average pain score), with 40% of the patients reaching this threshold by the third treatment day. Similar improvements were observed for pain interference scores. The HLT patch was generally well tolerated.

CONCLUSION

The HLT patch resulted in clinically meaningful reduction in pain intensity in the majority of patients with mild-to-moderate CTS and may represent a targeted nonsurgical treatment for pain associated with CTS.

Smoking and carpal tunnel syndrome: a meta-analysis

INTRODUCTION

We assessed the association between smoking and carpal tunnel syndrome (CTS) and estimated the magnitude of the association with meta-analysis.

METHODS

The PubMed, Embase, Scopus, and SciVerse databases were searched through December 2012. Thirteen studies were included in the meta-analysis.

RESULTS

Cross-sectional studies reported an association between current smoking and CTS (pooled odds ratio (OR) = 1.99, 95% confidence interval (CI) 1.38-2.60, I-squared = 0%). Meta-analyses of case-control studies did not, however, show an association between smoking and CTS (pooled OR = 1.04, 95% CI 0.95-1.12, I-squared = 0.0%) or surgery due to CTS (pooled OR = 0.99, 95% CI 0.82-1.15, I-squared = 0%). Moreover, smoking was not associated with CTS in the meta-analysis of cohort studies (pooled OR = 0.97, 95% CI 0.45-1.50, I-squared = 0%).

CONCLUSIONS

We found an association between smoking and CTS in cross-sectional studies. This association should be explored further in appropriately designed case-control and cohort studies. Muscle Nerve 49:345-350, 2014.