Investigating the association between diabetes and carpal tunnel syndrome: A systematic review and meta-analysis approach

INTRODUCTION

In recent years, several studies have reported on the relationship between diabetes and carpal tunnel syndrome (CTS). However, due to their contradictory results, a systematic review and meta-analysis were conducted to investigate this subject.

METHODS

This study is a systematic review and meta-analysis of studies published in ISI Web of Science, Scopus, PubMed, Cochrane, Google Scholar, and Embase databases. Heterogeneity in the studies included in the meta-analysis was evaluated using statistical tests such as the Chi-square test, I2, and forest plots. Publication bias was assessed using Begg's and Egger's tests.

RESULTS

This investigation analyzed data from 42 studies conducted between 1985 and 2022, with a total of 3,377,816 participants. The meta-analysis demonstrated that the odds ratio (OR) of CTS in participants with a history of diabetes compared to those without was 1.90 (95% CI: 1.64-2.21; P-value < 0.001). Given that publication bias was observed in this study (Begg's test P-value = 0.01), the modified OR was calculated with consideration of missed studies, which was 1.68 (95% CI: 1.45-1.94; P-value < 0.001).

CONCLUSION

The results of this study suggest that diabetic patients have 90% higher odds of developing CTS compared to non-diabetic individuals, which is statistically significant.

Is arthritis an associated risk factor for trigger finger occurrence after carpal tunnel release? A nationwide, population-based study in Korea

PURPOSE

We hypothesized that increased friction between the flexor tendon and surrounding structures due to hand arthritis is an important risk factor for trigger finger (TF) after carpal tunnel release (CTR). Therefore, we compared TF development according to the presence or absence of arthritis in carpal tunnel syndrome (CTS) patients treated with CTR.

METHODS

This retrospective study was based on data collected from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) in the Republic of Korea between January 1, 2002, and December 31, 2015. Patients diagnosed with TF between one month and one year after the CTR date or with a history of surgery were included in the study. During subsequent follow-up, the patients were divided into subgroups of those (1) with TF and (2) without TF. Sex, age, arthritis, and TF-related comorbidities were compared between the subgroups.

RESULTS

The subgroup with TF had a higher proportion of women (9.43% vs 90.57%), the highest age range between 50 and 59 years, more cases of arthritis (32.55% vs 16.79%), and a higher proportion of patients with hypothyroidism (10.85% vs 4.60%) than the group without TF. The association between arthritis and TF after CTR was examined using a multivariate logistic regression model, showing arthritis to be a significant risk factor for TF after CTR (odds ratio, 1.35; P = 0.049).

CONCLUSIONS

We identified arthritis as an important risk factor for the development of TF after CTR.

Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis

BACKGROUND

The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR.

METHODS

The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire.

RESULTS

A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery.

CONCLUSION

Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.

Prevalence of transthyretin cardiac amyloidosis in patients with high-degree AV block

OBJECTIVE

Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative cardiac disorder caused by deposition of wild type or mutated transthyretin. As ATTR-CM is associated with conduction disease, we sought to determine its prevalence in patients with idiopathic high-degree atrioventricular (AV) block requiring permanent pacemaker (PPM) implantation.

METHODS

Consecutive patients aged 70-85 years undergoing PPM implantation for idiopathic high-degree AV block between November 2019 and November 2021 were offered a 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scan. Demographics, comorbidities, electrocardiographic and imaging data from the time of device implantation were retrospectively collected.

RESULTS

39 patients (79.5% male, mean (SD) age at device implantation 76.2 (2.9) years) had a DPD scan. 3/39 (7.7%, all male) had a result consistent with ATTR-CM (Perugini grade 2 or 3). Mean (SD) maximum wall thickness of those with a positive DPD scan was 19.0 mm (3.6 mm) vs 11.4 mm (2.7 mm) in those with a negative scan (p=0.06). All patients diagnosed with ATTR-CM had spinal canal stenosis and two had carpal tunnel syndrome.

CONCLUSIONS

ATTR-CM should be considered in older patients requiring permanent pacing for high-degree AV block, particularly in the presence of left ventricular hypertrophy, carpal tunnel syndrome or spinal canal stenosis.

A Logistic Regression Analysis of Factors Associated with Guarded Outcome after Carpal Tunnel Release in Symptomatic Carpal Tunnel Syndrome

BACKGROUND

The Boston Carpal Tunnel Questionnaire (BCTQ) is a validated measurement tool to assess the severity of carpal tunnel syndrome, and improvements in the BCTQ after carpal tunnel release (CTR) have been demonstrated to influence patient satisfaction. The authors hypothesized that patient-related factors influence response in BCTQ subscales, including the Symptom Severity Scale and the Functional Status Scale, after CTR.

METHODS

Patients who underwent surgery with follow-up BCTQ were identified from a prospectively maintained database. Paired t tests were used to compare BCTQ subscales at each follow-up time point. Minimal clinically important differences were set. Patients below these thresholds were deemed as having failure to improve after CTR. Univariate analysis was used to identify risk factors for failure to improve after CTR. Multivariate logistic regression was used to identify independent predictors for failure to improve after CTR.

RESULTS

A total of 106 patients met inclusion criteria. Patients demonstrated significant improvements at all follow-up time points. The factor most associated with improvement beyond the minimal clinically important differences was a more severe score in the respective domain assessed. Other independent factors that influenced outcome after CTR included race, concomitant cubital tunnel release, sex, and age.

CONCLUSIONS

CTR results in significant improvements in BCTQ and its subscales, with improvements stabilizing after 6 weeks. In a select cohort of patients, failure to improve after CTR occurs with factors independently associated with a lower degree of improvement. Identification of patients with these risk factors will provide a basis for counseling and increased monitoring of patients at risk for a guarded prognosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Hyperglycaemia is a causal risk factor for upper limb pathologies

BACKGROUND

Diabetes (regardless of type) and obesity are associated with a range of musculoskeletal disorders. The causal mechanisms driving these associations are unknown for many upper limb pathologies. We used genetic techniques to test the causal link between glycemia, obesity and musculoskeletal conditions.

METHODS

In the UK Biobank's unrelated European cohort (N = 379 708) we performed mendelian randomisation (MR) analyses to test for a causal effect of long-term high glycaemia and adiposity on four musculoskeletal pathologies: frozen shoulder, Dupuytren's disease, carpal tunnel syndrome and trigger finger. We also performed single-gene MR using rare variants in the GCK gene.

RESULTS

Using MR, we found evidence that long-term high glycaemia has a causal role in the aetiology of upper limb conditions. A 10-mmol/mol increase in genetically predicted haemoglobin A1C (HbA1c) was associated with frozen shoulder: odds ratio (OR) = 1.50 [95% confidence interval (CI), 1.20-1.88], Dupuytren's disease: OR = 1.17 (95% CI, 1.01-1.35), trigger finger: OR = 1.30 (95% CI, 1.09-1.55) and carpal tunnel syndrome: OR = 1.20 (95% CI, 1.09-1.33). Carriers of GCK mutations have increased odds of frozen shoulder: OR = 7.16 (95% CI, 2.93-17.51) and carpal tunnel syndrome: OR = 2.86 (95% CI, 1.50-5.44) but not Dupuytren's disease or trigger finger. We found evidence that an increase in genetically predicted body mass index (BMI) of 5 kg/m2 was associated with carpal tunnel syndrome: OR = 1.13 (95% CI, 1.10-1.16) and associated negatively with Dupuytren's disease: OR = 0.94 (95% CI, 0.90-0.98), but no evidence of association with frozen shoulder or trigger finger. Trigger finger (OR 1.96 (95% CI, 1.42-2.69) P = 3.6e-05) and carpal tunnel syndrome [OR 1.63 (95% CI, 1.36-1.95) P = 8.5e-08] are associated with genetically predicted unfavourable adiposity increase of one standard deviation of body fat.

CONCLUSIONS

Our study consistently demonstrates a causal role of long-term high glycaemia in the aetiology of upper limb musculoskeletal conditions. Clinicians treating diabetes patients should be aware of these complications in clinic, specifically those managing the care of GCK mutation carriers. Upper limb musculoskeletal conditions should be considered diabetes complications.

Subjective and Objective Differences in Patients with Unilateral and Bilateral Carpal Tunnel Syndrome and the Role of Obesity in Syndrome Severity

BACKGROUND

It remains unclear whether physiologic differences exist in musculoskeletal ultrasound nerve measurements when comparing bilateral and unilateral carpal tunnel syndrome (CTS) patients. Similarly, the influence of body mass index on CTS severity is not well characterized.

METHODS

Unilateral and bilateral CTS patients were seen from October of 2014 to February of 2021. Obese and nonobese CTS patients were compared. Median nerve cross-sectional area (CSA), Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ), and six-item Carpal Tunnel Symptom Score (CTS-6) measures were obtained. Nerve conduction studies recorded distal motor latency (DML) and distal sensory latency (DSL). Statistical analysis used Wilcoxon signed rank testing for paired continuous variables, Mann-Whitney U testing for nonpaired continuous variables, and chi-square testing for continuous variables, with a significance level of P < 0.05.

RESULTS

A total of 109 (218 nerves) bilateral and 112 (112 nerves) unilateral CTS patients were reviewed. Bilateral patients had larger median nerve CSAs on their more symptomatic side, when defined by BCTSQ score ( P < 0.0001), CTS-6 score ( P < 0.0001), DML ( P < 0.0001), and DSL ( P < 0.01). Bilateral patients also had higher symptom severity scale ( P < 0.01) and DSL ( P < 0.001) outcomes compared with unilateral patients. Obese patients had higher median nerve CSA ( P < 0.01), prolonged DML, and prolonged DSL ( P < 0.0001) values despite similar CTS severity (BCTSQ and CTS-6).

CONCLUSIONS

Ultrasound identifies the more symptomatic side in bilateral patients, which correlates with increasing severity (NCS and BCTSQ). Obesity increases median nerve CSA and prolongs nerve conduction studies without influencing CTS severity. This information can be used when considering which diagnostic test to order for CTS.

Complications of operatively treated distal radial fractures

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Acroparesthesias: An Overview

Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.

Risk Factors and Outcomes in Carpal Tunnel Syndrome Following Distal Radius Open Reduction Internal Fixation

PURPOSE

Carpal tunnel syndrome (CTS) is a common complication following the operative repair of distal radius fractures. It is unclear who is at risk of developing this complication in the postoperative period. This study sought to identify risk factors for developing CTS and to evaluate patient-reported outcomes in patients who develop postoperative CTS.

METHODS

A retrospective review of all distal radius fractures treated surgically at a single private academic center was performed from January 2007 to October 2019. Of the 4,487 patients, 68 were identified to have an ipsilateral carpal tunnel release within 6 months of the distal radius injury. Collected data comprised patient demographics, medical history, and functional outcome scores.

RESULTS

Carpal tunnel syndrome was more likely to develop in older patients (62.9 years vs 57.4 years). Sex, body mass index, smoking history, and the type of insurance were not found to be significantly different between the groups. Medical history of kidney disease, psychiatric conditions, and peripheral vascular disease were found to be associated with developing CTS. Patients who developed CTS had higher average Disabilities of the Arm, Shoulder, and Hand scores than patients without CTS (28.1 vs 20.0) at the final follow-up. In a multivariable analysis, patients who developed CTS were found to be older (Odds ratio, 1.03) and less likely to be smokers (Odds ratio, 0.46).

CONCLUSIONS

In our cohort, we observed that older patients were more likely to require carpal tunnel release following distal radius fracture. In addition, nonsmokers were more likely to require subsequent carpal tunnel release, probably as a result of confounding effects. Special care should be taken to monitor these patients for CTS in the postoperative period following a distal radius open reduction and internal fixation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Health-related factors and dysregulation of epigenetic related genes in metabolic syndrome trigger finger patients and smoker trigger finger patients: preliminary analysis of patient-derived sample

PURPOSE

To investigate the health-related factors and analyze the expression of epigenetic related genes and inflammatory genes in metabolic syndrome Trigger Finger (TF) and smoker TF.

METHODS

Samples from patients' fingers with symptomatic TF were collected. There were seven groups: healthy control group, carpal tunnel syndrome (as a control for gene expression analysis), TF, diabetic TF, hypertensive TF, dyslipidemic TF and smoker TF. The expression levels of epigenetic related genes and inflammatory genes in metabolic syndrome TF and smoker TF were evaluated by the reverse transcription-polymerase chain reaction (RT-PCR) technique. The Perceived Stress Scale (PSS), Pittsburgh Sleep Quality Index (PSQI) questionnaires, disability of the arm, shoulder and hand (DASH) and numeric pain rating scale were given to the participants to fill out.

RESULTS

There was a significant increase in hand dysfunction in the metabolic TF groups and smoker group compared to the TF group (p < 0.0001). The stress levels of the smoker TF group and TF with hypertension group were significantly increased compared with those in the TF group (p < 0.03) and (p < 0.021), respectively. On the other hand, there was a significant increase in the COL-I, COL-II and TNF-α gene expression of the metabolic TF groups and smoker group (p < 0.0001).

CONCLUSIONS

Health-related factors in the TF tendons was highly associated with the level of inflammation and genetic alteration in TF metabolic syndromes and smoker TF patients. Therefore, further investigation is required to examine the combination of occupational therapy, gene expression, and health-related factors as a promising method of managing TF.

Diagnosis and Outcomes of 225 Consecutive Cases of Complex Regional Pain Syndrome of the Hand

BACKGROUND

The lack of specific tests and potential diagnostic inaccuracy may be behind the stunning figures of complex regional pain syndrome (CRPS) cases. The author tested the hypothesis that patients diagnosed with CRPS at referral could be assigned to recognized conditions and treated accordingly.

METHODS

From January of 2018 to April of 2021, 225 consecutive patients attended the author's office having been diagnosed with and treated for CRPS for an average of 16 ± 26 months. There were 180 women and 45 men; no patient was excluded.

RESULTS

All patients could be allocated in named conditions: 79 had a wrong diagnosis; seven had a true causalgia; 16 were dystonic-psychogenic hands; 20 presented a flare reaction; and 90 had an "irritative" carpal tunnel syndrome. The remaining 13 patients had a miscellany of symptoms within a substandard management setting. Surgery was offered to 175 with a correctable cause; 50 (20 of whom had a tangible cause responsible for their pain) declined, and their outcome is unknown. The remaining 125 were operated on and tracked for an average of 20 ± 9 months. In the operated group, pain dropped 7.5 ± 2.2 points ( P < 0.0001) on a numerical rating scale of 0 to 10. Disabilities of the Arm, Shoulder, and Hand questionnaire scores fell from 80 to 16 ( P < 0.0001). Patients who were operated on rated their satisfaction on a scale of 0 to 10 as 8.9 ± 1.9.

CONCLUSIONS

Unlike with CRPS, all patients in this series had a true, diagnosable condition explaining their clinical picture. Most patients who agreed to be operated on had a favorable outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Efficacy of intravenous alpha lipoic acid in the treatment of neuropatic pain due to carpal tunnel syndrome

Background and purpose

In this study, we analyzed the effect of oral and oral + intravenous Alpha-lipoic acid (ALA) treatment on pain level and physical examination findings in patients diagnosed with carpal tunnel syndrome (CTS).

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Methods

A total of 115 patients patricipa­ted in the study. Physiotherapy and wrist splint were first applied to all patients diag­nosed with CTS in the study. 40 patients were treated with oral ALA after iv. ALA the­rapy, 35 patients received only oral ALA treatment and 40 patients did not receive any medication. The patients were divided into 3 groups as those who received only splint treatment and physiotherapy, those who received oral ALA treatment, and those who received oral ALA treatment after iv. treat­ment. All patients were assessed be­fore the treatment, and at the 1st and 3rd months of the treatment. In clinical assessment, visual analog scale (VAS) forms were filled to define the pain severity, the Boston symptom severity scale (BSSS) and Boston functional status scale (BFDS) were filled for evaluating symptoms and functional status. 

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Results

VAS, BSSS and BFDS scores of the patients who were treated with intravenous and then oral ALA were found to be significantly lower at the end of both the 1st and 3rd months compared to the patients who received only oral ALA or no medication (p=0.001; p<0.001), (p=0.001; p<0.001), (p=0.006; p<0.001).

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Conclusion

We think that iv. ALA is effective in the treatment of symptoms associated with CTS.

 

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The role of ultrasound in determining the presence and severity of carpal tunnel syndrome in diabetic patients

Carpal tunnel syndrome (CTS) is seen in 5% of the population and 14%-30% in diabetics. Although electrophysiological tests are used as the gold standard method in the diagnosis, alternative methods are being studying. We aimed to investigate whether the measurement of median nerve cross-sectional area (CSA) by ultrasound is associated with the presence and severity of CTS. This prospective, cross-sectional observational study includes 128 randomly selected T2DM patients. Electrodiagnostic study was performed for all patients to diagnose CTS. Median nerve CSA were measured with ultrasound examination. The severity of the CTS was determined by Padua method. Among 128 diabetes mellitus (DM) patients, 54 (28%) had CTS and 53 (41%) had diabetic peripheral polyneuropathy. The mean duration of DM was 11.55 years. Median nerve CSAs of the patients were significantly higher in patients with CTS (CTS (-): 10.47 ± 2.67 vs CTS: (+) 12.37 ± 3.17; p < 0.001). Median nerve CSA cutoff value of >10 mm2 predicts the diagnosis of CTS. However, minimal, mild, and moderate CTS groups had similar CSA according to Padua classification (p > 0.05 for all). CSA measurement with ultrasonography can be used as an effective method in diagnosing severe CTS disease. However, median nerve CSA values should not be used to reveal the severity of CTS, in order not to miss the demonstration of minimal, mild, and moderate groups, as well as being an indicator of only the severe CTS group.

Median to ulnar nerve comparison on diagnosis of carpal tunnel syndrome in patients with diabetic polyneuropathy - A neurophysiological study

Background and purpose – To analyze the utility of median nerve (MN) to ulnar nerve (UN) comparative parameters on the diagnosis of carpal tunnel syndrome (CTS) in diabetic patients with distal symmetrical sensorimotor polyneuropathy (DSMPNP).

Methods – Patients who were referred to our electroneuromyography laboratory within the last two years were included. We compared the diagnostic accuracy values of traditional MN conduction parameters, and the MN-to-UN comparative tests on electrodiagnosis of CTS between the patients with DSMPNP involving the nerves of upper and lower extremities (UEI-positive group), and the ones without the involvement of upper extremities (UEI-negative group).

Results – There were 64 upper extremities in the UEI-positive group and 70 patients in the UEI-negative group. The most accurate traditional parameter was MN distal motor latency (DML) with a diagnostic accuracy of 70.2% whereas the most accurate comparative technique was the second lumbricalinterosseous DML difference (2L-INT DMLD) with an accuracy of 81.3%. (p=0.03). In addition, when compared diagnostic accuracy values of MN parameters with their corresponding comparative parameters in the UEI-positive group which carries the major diagnostic challenges for detecting co-morbid CTS, MN to UN minimum F wave latency (mFWL) difference, SNAP amplitude ratio on the ring finger (RF), and 2L-INT DMLD had higher accuracy values than MN mFWL, MN SNAP amplitude on RF, and MN DML on lumbrical muscle, respectively (p<0.05 for all comparisons).

Conclusion – MN to UN comparative studies have high accuracy values in electrodiagnosis of CTS in DSMPNP. In particular, 2L-INT DMLD could be helpful to overcome the diagnostic difficulty in the presence of UEI as an additional conduction technique.

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Point Blank: A Retrospective Review of Self-inflicted Gunshot Wounds to the Hand

BACKGROUND

A paucity of literature exists specifically examining self-inflicted (SI) gunshot wounds (GSWs) to the hand and wrist, which impart greater energy and have a higher risk of adverse events than non-self-inflicted (NSI) GSWs.

METHODS

We retrospectively reviewed records of patients who presented to our plastic surgery service after sustaining acute GSWs involving the hand and wrist between 2016 and 2018.

RESULTS

We identified 60 patients who sustained GSWs involving the hand and wrist; 17 (28%) were SI, and 43 (72%) were NSI. Within the SI group, 100% of patients were Caucasian, with an average age of 54 years. Within the NSI cohort, 77% of patients were Black, 19% were Caucasian, and 4% identified as other. While not statistically significant, we noted a substantial increase in patients requiring operative intervention in the SI cohort (65% SI vs 37% NSI, P = .08). There was a statistically significant increase in patients requiring more than 1 operation in SI patients (24% SI vs 5% NSI, P = .04). Patients who sustained SI injuries were also more likely to present with acute carpal tunnel syndrome requiring urgent surgical release and to develop wound infections (12% vs 0%, P = .08).

CONCLUSIONS

Self-inflicted GSWs involving the hand and wrist are associated with greater morbidity than their low-energy NSI counterparts. Individuals presenting with SI GSWs are more likely to be older, to require multiple operations, to develop infections, and to present with acute carpal tunnel syndrome requiring urgent surgical decompression.

[Rare variant of median nerve compression: compression by brachial artery false aneurysm combined with carpal tunnel syndrome. Case report and literature review]

BACKGROUND

The authors present severe compression of the median nerve by iatrogenic false aneurysm of the brachial artery combined with carpal tunnel syndrome.

MATERIAL AND METHODS

An 81-year-old woman developed acute anesthesia of fingers I-III of the left hand, impaired flexion of the thumb and forefinger, swelling of the hand and forearm, local pain in postoperative period after angiography. The patient was previously followed-up for transient numbness in both hands for 2 years with a diagnosis of carpal tunnel syndrome. Electroneuromyography and ultrasound of the median nerve at the level of shoulder and forearm were carried out. We visualized a pulsatile lesion with Tinel's sign within the elbow (false aneurysm of the brachial artery).

RESULTS

Resection of brachial artery aneurysm and neurolysis of the left median nerve were followed by regression of pain syndrome and improvement of motor function of the hand.

CONCLUSION

This case demonstrates a rare variant of acute high compression of the median nerve after diagnostic angiography. This situation should be considered in differential diagnosis with classical carpal tunnel syndrome.

The Interaction of Diabetic Peripheral Neuropathy and Carpal Tunnel Syndrome

BACKGROUND

Diabetes mellitus (DM) increases the risk for carpal tunnel syndrome (CTS) and is associated with its own neuropathic complications. Diabetic peripheral neuropathy (DPN) is a common complication seen in diabetic patients. In this study, we examine the relationship between the severity of DPN and CTS.

METHODS

Type 2 diabetic and control patients (n = 292) were recruited at a clinic visit. The Michigan Neuropathy Screening Instrument (MNSI) questionnaire was used to collect data related to peripheral neuropathy. The MNSI scores were compared for patients with CTS with and without DM in univariable and multivariable analyses. χ2 analyses were performed to quantitatively measure the associations between peripheral neuropathy and the presence of CTS.

RESULTS

Of the 292 patients, 41 had CTS, and 19 of these had both CTS and DM. Of the 138 diabetic patients, 85 had peripheral neuropathy. There was no association between a diagnosis of CTS and an MNSI score indicative of peripheral neuropathy. In the diabetic population, CTS was inversely associated with DPN (P = .017). The MNSI scores between diabetic and control patients with CTS were comparable.

CONCLUSION

The severity of peripheral neuropathy in diabetic patients with and without CTS is comparable. Diabetic patients without peripheral neuropathy have an association with higher incidence of CTS in this study, suggesting that there are disparate mechanisms causing DPN and CTS. Nevertheless, diabetes and CTS are risk factors for developing the other, and future studies should further explore how DPN and CTS differ to tailor patient interventions based on their comorbidities.

Neuropathic upper extremity pain: A double-crush scenario

ABSTRACT

Neuropathic upper extremity pain has many causes. Cubital tunnel syndrome is the second most common compressive peripheral neuropathy after carpal tunnel syndrome. Entrapment, or compression, of the ulnar nerve at the elbow classically presents with elbow pain, numbness in the ulnar nerve distribution, and weakness in the hand. C8 radiculopathy and various brachial plexopathies can mimic cubital and carpal tunnel syndromes. Neoplastic brachial plexopathy typically is caused by local extension of a primary or metastatic tumor into the brachial plexus. Double-crush syndrome further complicates neuropathic upper extremity pain. This case report describes a patient with a double-crush lesion involving the ulnar nerve at the elbow and a metastatic mass involving the lower trunk of the brachial plexus. Because of overlapping symptoms and presentations of several upper extremity nerve conditions, clinicians must perform a thorough history and physical examination and understand the sensory and motor innervation of the upper extremity to arrive at a timely and accurate diagnosis.

Evaluation of Functional and Symptomatic Outcomes After Vitamin D3 Administration in Carpal Tunnel Syndrome With Hypovitaminosis D

BACKGROUND

Vitamin D deficiency is now recognized as an independent risk factor and is involved in the pathogenesis of carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the effects of vitamin D3 supplementation on functional and symptomatic outcomes in CTS patients with vitamin D deficiency.

METHODS

This was a prospective, single-arm study with a pretreatment or posttreatment quasi-experimental design. Carpal tunnel syndrome patients with vitamin D deficiency were treated with vitamin D3 (60 000 IU/week) plus standard treatment for a period of 3 months. Carpal tunnel syndrome-related pain and functional and symptomatic outcomes were assessed at baseline and at 3 months posttreatment using the Visual Analogue Scale (VAS) and the Boston Carpal Tunnel Questionnaire, respectively, along with serum vitamin D.

RESULTS

A total of 42 patients were analyzed. At 3 months posttreatment, there was a significant reduction in the severity of pain (VAS score) from baseline (Z = -5.71, P < .001). Similarly, the functional and symptomatic outcomes (Boston symptoms severity scale [SSS] and Boston functional status scale [FSS] score) at 3 months posttreatment significantly improved in comparison with baseline (Boston SSS: Z = -5.66, P < .001; Boston FSS: Z = -5.68, P < .001).

CONCLUSIONS

Vitamin D3 supplementation was associated with improvement in functional and symptomatic outcomes and CTS-related pain in CTS with vitamin deficiency. However, further robust randomized controlled trials are warranted to validate the results.

Long-term Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance

BACKGROUND

The purpose of this study was to determine the long-term safety and efficacy of carpal tunnel release (CTR) using ultrasound guidance in a group of patients treated by a single physician.

METHODS

The study group consisted of 76 consecutive CTRs performed on 47 patients between June 2017 and April 2019 for whom 1-year follow-up was available. All procedures were performed by the same operator using a single CTR technique. Outcomes included complications; Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores; Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) scores; and a 5-point global satisfaction score (4 = satisfied, 5 = very satisfied).

RESULTS

The 47 patients included 27 females and 20 males (ages 31-91 years). Twenty-five patients (50 hands) had simultaneous bilateral CTRs, 4 patients (8 hands) had staged bilateral CTRs, and 18 patients had unilateral CTRs. No complications occurred. Statistically and clinically significant reductions in BCTQ-SSS, BCTQ-FSS, and QDASH scores occurred by 1 to 2 weeks post-CTR and persisted at 1-year (mean 1-year changes vs. pre-CTR -2.11, -1.70, and -44.99, respectively; P < .001 for all). The mean global satisfaction score at 1-year was 4.63.

CONCLUSIONS

CTR using ultrasound (US) guidance is a safe and effective procedure that produces statistically and clinically significant improvements within 1 to 2 weeks postprocedure that persist to 1 year. Furthermore, simultaneous bilateral CTRs using US guidance are feasible and may be advantageous for patients who are candidates for bilateral CTR.

Clinical Characteristics and Treatment of Adult Idiopathic Carpal Tunnel Syndrome Accompanied with Trigger Digit

Purpose

To investigate the clinical characteristics and treatment of adult idiopathic carpal tunnel syndrome (CTS) accompanied with trigger digit.

Materials and Methods

A retrospective analysis was performed on a total of 74 patients with adult idiopathic CTS accompanied with trigger digit admitted to and treated at the Hand Surgery Department of Ningbo No. 6 Hospital from January 1, 2017 to December 31, 2019. Data on patients' gender, age, occupation, course of the disease, menstruation, surgeries, examination-related information, complications, treatment methods, and prognoses during follow-up were recorded and subsequently used to analyze the pathogeneses, clinical characteristics, and treatment.

Results

A total of 74 patients (72 females and 2 males) were included. Among female patients, 51 were postmenopausal and 18 were non-postmenopausal. There were 101 fingers with trigger digit, including 14 patients with trigger digit in both hands, and 115 wrists affected by the CTS. The average course of CTS was 34.5 ± 49.3 months, and that of trigger digit was 10.5 ± 22.4 months. Seventy had both trigger digit and CTS in one hand, while among patients with both hands involved, only 4 had trigger digit or CTS in one hand. Eighty-nine fingers underwent A1 pulley release, and 104 hands underwent carpal tunnel surgery, with steroids being injected under the adventitia of the median nerve during the surgery. All patients who underwent surgeries had I/A-healed incisions, and 14 of them had obvious synovial hyperplasia observed in the carpal tunnel and flexor tendon sheath during surgeries. Follow-up visits, which lasted 3 to 35 months, had an average duration of 1.34 years and included 72 patients. In 63 patients (63/72), the syndrome of tenosynovitis and numbness disappeared and normal hand functions were restored; in 6 patients, the numbness in hands greatly improved and normal hand functions were almost completely restored, while no improvement in numbness of hands and limited hand functions were still observed in 3 patients.

Conclusion

CTS accompanied with trigger digit was more common in postmenopausal females, and the course of CTS was longer than that of trigger digit. CTS and trigger digit were more likely to simultaneously occur in the same hand, while some patients might not have obvious synovial hyperplasia in the carpal tunnel. Surgeries were effective in severe cases.

Carpal tunnel release under wide awake local anesthesia with no tourniquet in hemodialysis patients with arteriovenous shunt

INTRODUCTION

Long-term hemodialysis patients experience many hand diseases caused by dialysis-related amyloidosis (DRA), with carpal tunnel syndrome (CTS) being the most common. For the patients with arteriovenous (AV) shunt, surgical decompression remains challenging because of the contraindications of a tourniquet. A technique called wide-awake local anesthesia with no tourniquet (WALANT), in which epinephrine provides hemostasis instead of the tourniquet, can be a good option for hemodialysis patients. The purpose of this study was to assess the prevalence of CTS and related factors in hemodialysis patients, and to establish the efficacy and safety of WALANT on hemodialysis patients with AV shunt.

MATERIALS AND METHODS

This prospective study included 275 hemodialysis patients between March 2013 and July 2019. 43 patients were diagnosed with CTS, involving surgical treatment on 70 wrists. We performed mini-open carpal tunnel release using WALANT on the AV shunt arm (defined as the WALANT group), while using lidocaine and a tourniquet on the arm without an AV shunt (defined as the tourniquet group). The operative time, surgical field bleeding (blood loss and hemostasis score), surgical pain (injection pain and tourniquet pain), outcomes, complications, and satisfaction were compared between the two groups.

RESULTS

The incidence of CTS in hemodialysis patients was 15.6%. Longer dialysis durations were related to higher proportions of patients with CTS. There was no significant difference in blood loss (p=0.184) and hemostasis score (p=0.165) between the two groups. Clinical symptoms improved in all patients, and there were no severe complications. The WALANT group had a significantly longer preparation time of approximately 20minutes, but they had low injection pain and no tourniquet pain. There was also no significant difference in terms of satisfaction levels (p=0.212).

DISCUSSION

CTS is a very common disease among hemodialysis patients. WALANT provided sufficient hemostasis without a tourniquet, despite the patients' high bleeding tendency. The technique also had the advantages of low injection pain, no tourniquet pain, and no major complications. In this respect, WALANT can be a good choice for hemodialysis patients with AV shunt.

LEVEL OF EVIDENCE

II.

Separating Fact From Fiction: A Nationwide Longitudinal Examination of Complex Regional Pain Syndrome Following Treatment of Dupuytren Contracture

BACKGROUND

One of the most feared complications following treatment of Dupuytren contracture is complex regional pain syndrome (CRPS). This study aims to provide a national perspective on the incidence of CRPS following treatment of Dupuytren contracture and identify patient factors to target for risk reduction.

METHODS

Using the Truven MarketScan databases from 2007 to 2016, individuals aged ≥18 years who developed CRPS within 1 year of treatment of Dupuytren contracture were identified using the International Classification of Disease diagnosis code for CRPS. Predictor variables included: age, sex, employment status, region, type of procedure, and concurrent carpal tunnel surgery. Multivariable logistic regression was used to analyze outcomes.

RESULTS

In all, 48 327 patients received treatment for Dupuytren contracture, including collagenase injection (13.6%); percutaneous palmar fasciotomy (10.3%); open palmar fasciotomy (3.9%); palmar fasciectomy with 0 (10.8%), 1 (29.2%), or multiple (19.6%) digit releases; or a combination of these procedures (12.8%). One hundred forty-five patients (0.31%) were diagnosed with CRPS at a mean of 3.4 months (standard deviation, 2.3) following treatment. Significant predictors of CRPS included female sex (odds ratio [OR], 2.02; P < .001), Southern region (OR, 1.80; P = .022), long-term disability status (OR, 4.73; P = .035), palmar fasciectomy with release of 1 (OR, 5.91; P = .003) or >1 digit (OR, 13.32; P < .001), or multiple concurrent procedures for Dupuytren contracture (OR, 8.23; P = .001).

CONCLUSIONS

Based on national commercial claims data, there is a lower incidence of CRPS following treatment of Dupuytren contracture than previously reported. Risk factors identified should help with preoperative counseling and assist clinicians in targeting risk reduction measures.

Surgeons' Recommendations for Neurodiagnostic Testing With High Pretest Probability of Idiopathic Median Neuropathy at the Carpal Tunnel

PURPOSE

The utility of electrodiagnostic tests (EDx) for patients with a high pretest probability of idiopathic median neuropathy at the carpal tunnel (IMNCT) based on characteristic symptoms and signs is debated. Decision-making and care strategies could be informed by a better understanding of factors associated with surgeon recommendations for electrodiagnostic testing.

METHODS

Ninety-one upper-extremity surgeons participated in an online, survey-based experiment. Participants viewed 7 vignettes of patients with carpal tunnel syndrome, with the following factors randomized in each vignette: patient age, gender, magnitude of incapability, symptom intensity and the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. We sought patient and surgeon factors associated with ordering EDx and surgeon-rated comfort with performing carpal tunnel release (CTR) without EDx.

RESULTS

Surgeons recommended EDx for over half of the patient vignettes, with notable variation (median, 57%; interquartile range, 14-100), and felt relatively neutral, on average, offering CTR without EDx. Twenty-six (29%) out of 91 surgeons ordered EDx for all patient scenarios, and 18 surgeons (20%) did not order testing for any scenario. A lower likelihood of EDx was associated with older age and positive provocative tests results. Greater surgeon comfort offering CTR without EDx was associated with older patients, the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results.

CONCLUSIONS

Upper-extremity surgeons are neutral regarding diagnosing IMNCT based on electrodiagnostic evidence of pathology and are relatively more comfortable offering surgery without EDx in older patients that present with key aspects of carpal tunnel syndrome. There is notable variation in care, with half of all surgeons always or never ordering EDx.

CLINICAL RELEVANCE

Future studies can investigate whether a treatment strategy offering surgery to patients with a high pretest probability of IMNCT and only using EDx in intermediate probability scenarios can limit use of testing without affecting patient health.

Systemic inflammatory markers in neuropathic pain, nerve injury, and recovery

ABSTRACT

The role that inflammation plays in human nerve injury and neuropathic pain is incompletely understood. Previous studies highlight the role of inflammation in the generation and maintenance of neuropathic pain, but the emerging evidence from the preclinical literature for its role in the resolution of neuropathic pain remains to be explored in humans. Here, we use carpal tunnel syndrome (CTS) as a human model system of nerve injury and neuropathic pain to determine changes in serum cytokine protein levels and gene expression levels before (active stage of disease) and after carpal tunnel decompression surgery (recovery). Fifty-five patients with CTS were studied, and 21 healthy age-matched and gender-matched participants served as controls. In the active stage of the disease (CTS before surgery vs healthy controls), PTGES2 mRNA was decreased in patients (adjusted P = 0.013), while transforming growth factor-β and C-C motif chemokine ligand 5 protein levels were increased (adjusted P = 0.016 and P = 0.047, respectively). In the resolution phase (CTS before surgery vs after surgery), IL-9 mRNA was increased after surgery (adjusted P = 0.014) and expression of IL-6 mRNA and IL-4 protein levels were increased before surgery (adjusted P = 0.034 and P = 0.002, respectively). IL-9 mRNA expression negatively correlated with several (neuropathic) pain scores. By contrast, protein levels of IL-4 positively correlated with pain scores. In conclusion, we demonstrate specific dysregulation of systemic cytokine expression in both the active and resolution phases of nerve injury and neuropathic pain. IL-9 represents an interesting candidate associated with resolution of nerve injury and neuropathic pain.

Carpal Tunnel Syndrome in Diabetes Mellitus

The aim of the present brief review was to discuss carpal tunnel syndrome (CTS) in diabetes mellitus (DM). Generally, CTS is more common in DM, especially in subjects with coexisting diabetic polyneuropathy (DPN) and/or long DM duration. There is no agreement if it is more frequent in type 1 or type 2 DM. The precise underlying mechanisms are not entirely clear but appear to involve hyperglycaemia-induced median nerve oedema, increased sensitivity to exogenous trauma and nerve myelin ischaemia and axonal degeneration. More recently, increased vascular endothelial growth factor (VEGF) and advanced glycation endproducts (AGEs) appear to also play an important role. Median nerve conduction study remains the cornerstone of CTS diagnosis in DM, being more sensitive than clinical examination. CTS can be treated medically or surgically. The latter appears now to be equally effective in subjects with vs. without DM in terms of recurrence rates and quality of life.

Comparison of the Therapeutic Effect of the Mini-Open Incision and Conventional Open Neurolysis of the Median Nerve for Carpal Tunnel Syndrome

OBJECTIVE

The aim of this study was to compare the therapeutic effects of the mini-open incision and conventional open surgery for carpal tunnel syndrome (CTS).

METHODS

The clinical data of 52 patients with CTS treated at the First Affiliated Hospital of the University of Science and Technology of China from October 2020 to February 2022 were retrospectively analyzed. The patients were divided into the conventional open surgery group (28 cases) and the mini-open incision group (24 cases) according to different surgical incisions applied. The incision length, operation time, time until postoperative return to work, and complications were observed in the two groups. The Visual Analog Scale (VAS) for pain at one day, one month, and three months after surgery and the Boston Carpal Tunnel Questionnaire scores before, at one month, and at three months after surgery were compared between the two groups.

RESULTS

The incision length, operation time, and time until return to work in the mini-open incision group were all shorter than those in the conventional open surgery group (2.58 ± 0.35 vs. 7.32 ± 0.61 cm, 18.67 ± 2.62 vs. 29.46 ± 3.42 min, and 5.33 ± 1.40 vs. 13.86 ± 2.70 d, respectively), and differences were statistically significant (P < 0.05 in all). The VAS scores in the mini-open incision group were lower than those in the conventional open surgery group at one day and one month after surgery, while the difference in the VAS scores at three months after surgery was not statistically significant between the two groups. There was no statistically significant difference in neurological recovery between the two groups at postoperative follow-ups (P > 0.05). The incidences of postoperative scar hyperplasia and scar pain were higher in the conventional open surgery group than those in the mini-open incision group, and differences were statistically significant (P < 0.05 in both).

CONCLUSION

Mini-open incision surgery for CTS was a safe and reliable procedure with a precise therapeutic effect, minimal surgical trauma, and high postoperative comfort for patients and could achieve enhanced recovery. Trial Registration. This trial is registered with ChiCTR2200064631.

Responsiveness of quantitative sensory testing-derived sensory phenotype to disease-modifying intervention in patients with entrapment neuropathy: a longitudinal study

ABSTRACT

The German Research Network on Neuropathic Pain (DFNS) quantitative sensory testing (QST) method for sensory phenotyping is used to stratify patients by mechanism-associated sensory phenotype, theorised to be predictive of intervention efficacy. We hypothesised that change in pain and sensory dysfunction would relate to change in sensory phenotype. We investigated the responsiveness of sensory phenotype to surgery in patients with an entrapment neuropathy. With ethical approval and consent, this observational study recruited patients with neurophysiologically confirmed carpal tunnel syndrome. Symptom and pain severity parameters and DFNS QST were evaluated before and after carpal tunnel surgery. Surgical outcome was evaluated by patient-rated change. Symptom severity score of the Boston Carpal Tunnel Questionnaire and associated pain and paraesthesia subgroups were comparators for clinically relevant change. Quantitative sensory testing results (n = 76) were compared with healthy controls (n = 54). At 6 months postsurgery, 92% participants reported a good surgical outcome and large decrease in pain and symptom severity (P < 0.001). Change in QST parameters occurred for thermal detection, thermal pain, and mechanical detection thresholds with a moderate to large effect size. Change in mechanical pain measures was not statistically significant. Change occurred in sensory phenotype postsurgery (P < 0.001); sensory phenotype was associated with symptom subgroup (P = 0.03) and patient-rated surgical outcome (P = 0.02). Quantitative sensory testing-derived sensory phenotype is sensitive to clinically important change. In an entrapment neuropathy model, sensory phenotype was associated with patient-reported symptoms and demonstrated statistically significant, clinically relevant change after disease-modifying intervention. Sensory phenotype was independent of disease severity and may reflect underlying neuropathophysiology.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Carpal tunnel syndrome in acromegaly: a nationwide study

OBJECTIVE

Carpal tunnel syndrome (CTS) is common in patients with acromegaly, with a reported prevalence of 19-64%. We studied CTS in a large national cohort of patients with acromegaly and the temporal relationship between the two diagnoses.

DESIGN

Retrospective, nationwide, cohort study including patients diagnosed with acromegaly in Sweden, 2005-2017, identified in the Swedish Healthcare Registries.

METHODS

CTS (diagnosis and surgery in specialised healthcare) was analysed from 8.5 years before the diagnosis of acromegaly until death or end of the study. Standardised incidence ratios (SIRs) with 95% CIs were calculated for CTS with the Swedish population as reference.

RESULTS

The analysis included 556 patients with acromegaly (50% women) diagnosed at mean (s.d.) age 50.1 (15.0) years. During the study period, 48 patients were diagnosed with CTS and 41 patients underwent at least one CTS surgery. In the latter group, 35 (85%) were operated for CTS before the acromegaly diagnosis; mean interval (range) 2.2 (0.3-8.5) years and the SIR for having CTS surgery before the diagnosis of acromegaly was 6.6 (4.8-8.9). Women with acromegaly had a higher risk for CTS than men (hazard ratio: 2.5, 95% CI: 1.3-4.7).

CONCLUSIONS

Patients with acromegaly had a 6-fold higher incidence for CTS surgery before the diagnosis of acromegaly compared with the general population. The majority of patients with both diagnoses were diagnosed with CTS prior to acromegaly. Increased awareness of signs of acromegaly in patients with CTS might help to shorten the diagnostic delay in acromegaly, especially in women.

Simultaneous Bilateral Carpal and Cubital Tunnel Releases: Quadruple Tunnel Release

The authors retrospectively reviewed the first 30 patients who underwent bilateral simultaneous carpal and cubital releases (quadruple tunnel release). Patients were asked to complete a questionnaire over the phone regarding their satisfaction with the procedures and willingness to make the same choice of bilateral carpal and cubital releases simultaneously, as well as the time to return to unrestricted use. Of 24 patients who responded to the questionnaire, 23 (95.8%) were satisfied or highly satisfied with their care, and 23 (95.8%) would again choose to have release of the 4 tunnels simultaneously. Time to unrestricted use in this patient cohort averaged 27 days. Quadruple tunnel release is technically feasible and well tolerated. This procedure has the potential to save considerable amounts of recuperation time and is less expensive than performing 4 individual procedures for patients who have bilateral carpal and bilateral cubital tunnel syndrome. [Orthopedics. 2020;43(6):e592-e594.].

Occurrence of cold sensitivity in carpal tunnel syndrome and its effects on surgical outcome following open carpal tunnel release

Cold sensitivity is common following nerve injuries in the upper extremity, but is less well studied in carpal tunnel syndrome (CTS). We investigated cold sensitivity in CTS and its effects on surgical outcome. A search of the Swedish National Registry for Hand Surgery (HAKIR) for open carpal tunnel releases (OCTR) from 2010-2016 identified 10,746 cases. Symptom severity questionnaires (HQ-8; HAKIR questionnaire 8, eight Likert-scale items scored 0-100, one item on cold sensitivity) and QuickDASH scores before and after surgery were collected. Patient mean age was 56 ± SD 16 years, and 7,150/10,746 (67%) were women. Patients with severe cold sensitivity (defined as cold intolerance symptom severity score > 70; n = 951), scored significantly higher on QuickDASH at all time points compared to those with mild cold sensitivity (cold intolerance symptom severity scores ≤ 30, n = 1,532); preoperatively 64 [50-75] vs. 40 [25-55], at three months 32 [14-52] vs. 18 [9-32] and at 12 months 25 [7-50] vs. 9 [2-23]; all p < 0.0001. Severe cold sensitivity predicted higher postoperative QuickDASH scores at three [12.9 points (95% CI 10.2-15.6; p < 0.0001)] and at 12 months [14.8 points (11.3-18.4; p < 0.0001)] compared to mild cold sensitivity, and adjustment for a concomitant condition in the hand/arm, including ulnar nerve compression, did not influence the results. Cold sensitivity improves after OCTR. A higher preoperative degree of cold sensitivity is associated with more preoperative and postoperative disability and symptoms than a lower degree of cold sensitivity, but with the same improvement in QuickDASH score.

Acupuncture for Carpal Tunnel Syndrome: A Randomized Controlled Trial Studying Changes in Clinical Symptoms and Electrodiagnostic Tests

BACKGROUND

Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy in humans. Nonsurgical management is still a matter of debate, and conservative treatments include splinting, local steroid injections, ultrasound, and oral steroids. Acupuncture and electroacupuncture therapy for symptomatic CTS may improve symptoms and aid nerve repair as well as improve sensory and motor functions. However, limited evidence based on comprehensive evaluation methods is available regarding the effects of those treatments.

OBJECTIVE

The study intended to compare the short-term effects of acupuncture and conventional medical treatment on CTS patients' clinical symptoms and on the results of their electrodiagnostic tests.

DESIGN

The research team designed a randomized controlled trial.

SETTING

The study took place at the electrodiagnostic clinic of the School of Persian and Complementary Medicine at Mashhad University of Medical Sciences (Mashhad, Iran).

PARTICIPANTS

Participants were 60 patients at the clinic with the clinical diagnosis of CTS.

INTERVENTIONS

Participants were randomly assigned to 1 of 2 groups. Patients in the control group received 100 mg of Celebrex as tablets, 2 times daily. Patients in the intervention group received 12 sessions of acupuncture, each for 30 min, for 4 wk. The needle insertion points were fixed for all sessions. In addition, wrist braces were provided to wear at night for 1 mo in both groups.

OUTCOME MEASURES

At baseline, postintervention at the end of week 4, and at a 3-mo follow-up at the end of week 16, participants' clinical symptoms-pain, numbness, tingling, weakness/clumsiness, and night awakenings-and the results of their electrodiagnostic studies were evaluated and compared.

RESULTS

In total, 49 patients completed the study-24 in the control group and 25 in the intervention group. Compared with the control group, the intervention group's clinical symptoms-pain, numbness, tingling, and muscular weakness-based on the subscales of the global symptoms score questionnaire as well as the overall score on that questionnaire improved significantly (P < .05). Regarding the electrodiagnostic studies, only the distal motor latency showed a significantly greater decrease in the acupuncture group in comparison to controls (P = .001).

CONCLUSION

All clinical symptoms and the results of the electrodiagnostic tests improved significantly in the intervention group, and the improvements continued during the 3 mo postintervention. The therapeutic results of acupuncture were mostly similar to and in certain cases better than those of the conventional medical treatment. Therefore, acupuncture can be suggested as a safe and suitable therapeutic method in CTS.

Elevated Preoperative Hemoglobin A1c Associated with Increased Wound Complications in Diabetic Patients Undergoing Primary, Open Carpal Tunnel Release

BACKGROUND

An increased rate of complications has been demonstrated with increasing hemoglobin A1c value for a variety of orthopedic procedures, including arthroplasty and spine surgery. The authors investigated the effects of elevated hemoglobin A1c value on postoperative complications at the time of carpal tunnel release.

METHODS

This retrospective, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of primary, open carpal tunnel release at a single academic institution within the past 10 years. Binary hemoglobin A1c thresholds were tested for association with outcomes of superficial or deep infection, delayed wound healing, and persistent symptoms using chi-square analysis. Multivariable models with adjustment for baseline and operative factors were then constructed. Odds ratios and 95 percent confidence intervals were displayed.

RESULTS

Hemoglobin A1c value greater than or equal to 7.8 percent was most strongly associated with an increased risk of all-cause wound healing complications (p = 0.049) at an odds ratio of 4.2 (95 percent CI, 1.0 to 17.7) in adjusted analyses. Six patients (4 percent) experienced delayed wound healing and five patients (4 percent) developed a superficial infection. Six patients (4 percent) reported persistent carpal tunnel syndrome symptoms.

CONCLUSIONS

Diabetic patients undergoing open, primary carpal tunnel release with a hemoglobin A1c value of 7.8 percent or higher had a higher rate of postoperative wound complications compared to diabetic patients with improved preoperative glucose control. Diabetics with poor glycemic control should be counseled that their risk of postoperative complication is higher. Further work is needed to determine whether delaying surgery to optimize glucose control could result in a reduction of wound healing complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Acute Carpal Tunnel Syndrome in Inpatients With Operative Distal Radius Fracture

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [Orthopedics. 2019; 42(4):227-234.].

Ultrasound-guided insulin injection for carpal tunnel syndrome in type 2 diabetes mellitus patients

OBJECTIVE

To compare effectiveness of ultrasound-guided local insulin injection, local steroid injection, and local steroid followed by insulin injections in treating mild to moderate carpal tunnel syndrome (CTS) in type 2 diabetes mellitus (DM).

METHOD

Study included 60 patients with electrophysiologic evidence of mild to moderate CTS. They were randomly divided into three groups: group I received insulin injection locally into the affected carpal tunnel at first visit and a similar dose after 2 weeks; group II received single injection of 40 mg methylprednisolone acetate injection; and group III received steroid injection then followed by insulin injection twice after 2 and 4 weeks. All injections were performed with ultrasonographic guidance. All patients were assessed by modified Boston Carpal Tunnel Questionnaire (FD score), CTS severity score (SS score), and neurophysiological and ultrasonographic assessments at baseline and 10 weeks after treatment.

RESULTS

A significant improvement in mean FD score, SS score, DML (distal motor latency), SNCV (sensory nerve conduction velocity), PSL (peak sensory latency), Samp (sensory amplitude), and CSA (cross-sectional area of median nerve) observed in all groups (with exception of mean DML and Samp in the second group and mean Samp in the third group). Group III showed significant improvement in CSA especially when compared to group II by post hoc analysis (P = 0.005).

CONCLUSIONS

Local insulin injection is as effective as steroid in treating mild to moderate CTS in type 2 DM and is a safer alternative. Adding insulin injections after steroid shows more sonographic improvement than steroid alone. Key Points • Local insulin injection is as effective as steroid in treating mild to moderate CTS in type 2 diabetic patients. • Measuring CSA of median nerve at CT inlet by US is a better tool for monitoring median nerve changes after treatment. • Adding insulin injections after steroid has more sonographic improvement than steroid alone.

Ultrasound-Guided Hydroneurolysis of the Median Nerve for Recurrent Carpal Tunnel Syndrome

BACKGROUND

Recurrent carpal tunnel syndrome is often associated with perineural scarring around the median nerve. Surgical options include relatively invasive procedures, such as fat pad grafting, ligament reconstruction, muscle transfer, and nerve wraps. All have limited success because of the possibility of repeated recurrent scarring postoperatively.

METHODS

We discuss a technique involving injection with external hydroneurolysis of the median nerve under ultrasound guidance for recurrent carpal tunnel. Injection enables a gentler dissection of the surrounding tissues compared with open external neurolysis, with less chance of recurrent scarring. This technique is a unique alternative to repeat operative intervention in recurrent carpal tunnel, as well as a prelude to repeat open decompression and salvage procedures.

RESULTS

Ultrasound-guided injection with external hydroneurolysis of the median nerve is a safer, more limited procedure compared with repeat open surgery, usually performed in an office setting. This procedure limits risk, anesthesia, and operating/recovery room expenses, offering relief in 70% to 80% of cases. Furthermore, in the 20% to 30% of patients with inadequate relief, surgery remains a viable option. US provides important information on the anatomy of the median nerve and carpal canal and can rule out covert pathology.

CONCLUSIONS

We offer an alternative treatment for recurrent carpal tunnel syndrome, a difficult problem for which many surgeons recommend nonoperative treatment. US provides objective data concerning residual nerve compression and allows for dynamic assessment. Theoretically, this also offers a viable solution for surgeons and their patients with recurrent carpal tunnel syndrome before being pressed to consider repeat open surgery.

Signs and symptoms of acromegaly at diagnosis: the physician's and the patient's perspectives in the ACRO-POLIS study

PURPOSE

Acromegaly is characterized by a broad range of manifestations. Early diagnosis is key to treatment success, but is often delayed as symptomatology overlaps with common disorders. We investigated sign-and-symptom associations, demographics, and clinical characteristics at acromegaly diagnosis.

METHODS

Observational, cross-sectional, multicenter non-interventional study conducted at 25 hospital departments in France that treat acromegaly (ClinicalTrials.gov: NCT02012127). Adults diagnosed with acromegaly < 5 years were enrolled. Demographic and clinical data were obtained from medical reports and patient questionnaires. Sign-and-symptom associations were assessed by multiple correspondence analysis (MCA).

RESULTS

Overall, 472 patients were included in the analyses. MCA was unsuccessful in identifying sign-and-symptom associations at diagnosis. Endocrinologists (29.5% patients) and other clinical specialists (37.2% patients) were commonly first to suspect acromegaly. Morphologic manifestations (83.7-87.9% patients), snoring syndrome (81.4% patients), and asthenia (79.2% patients) were frequently present at diagnosis; differences were found between sexes for specific manifestations. Rates of discrepancy between patient- and physician-reported manifestations were highest for functional signs. Earliest manifestations prior to diagnosis, according to how they were detected, were enlarged hands and feet (6.4 ± 6.8 and 6.2 ± 6.9 years, functional signs), hypertension (6.6 ± 7.5 years, complementary examination) and carpal/cubital tunnel syndrome (5.7 ± 6.7 years, functional signs with complementary examination).

CONCLUSIONS

Results confirm the broad range of manifestations at diagnosis and delay in recognizing the disease. We identified early manifestations and sex differences that may aid physicians in diagnosing acromegaly. Discrepancy rates suggest physicians should obtain the patient's perspective and seek functional signs during diagnosis.

Unusual case of hypotenar Hammer Syndrome and carpal tunnel syndrome association

BACKGROUND AND AIM OF THE WORK

Hypothenar Hammer Syndrome is a relatively rare disease process caused by repetitive stress or injury to the hypothenar eminence leading to chronic injury to the ulnar artery. Our study reports an unusual case.

METHODS

A 57 years old Plumber presented in April 2016 with a history of constant pain and recurrent paresthesia involving the fingers of the right hand for several months, over the previous 1 year, his hand had become more intolerant of exposure to cold temperatures. Angio-RNM and electromyography were performed and showed a severe double compression of ulnar and median nerve and an ulnar artery deformity without thrombosis. Surgery was performed under sedation and axillary anesthesia.

RESULTS

After surgery patient' symptoms immediately improved, and within a few months, his hand had normalized.

CONCLUSION

Hypothenar Hammer Syndrome is a rare disease process which manifests in certain occupations and activities that put undue stress on the hypothenar area. Furthermore, the carpal tunnel syndrome, a pressure damage of the median nerve, caused by repetitive manual tasks with flexion and extension of wrist has been added as well as hypothenar hammer syndrome which are vascular damages of hand caused by shock-type application of force.

Carpal tunnel syndrome caused by synovial osteochondromatosis of the finger flexor tendon: A case report

RATIONALE

Carpal tunnel syndrome (CTS) is the most common peripheral nerve neuropathy resulting from compression of the median nerve as it traverses the carpal tunnel. The pathophysiology of this condition is multifactorial, and majority of cases of CTS are idiopathic. We report cases of CTS caused by synovial osteochondromatosis (SOC), which has rarely been reported.

PATIENT CONCERNS

A 45-year-old female was admitted to the clinic due to right hand tingling sensation for 4 months. On physical examination, the patient's symptoms and signs corresponded to the median nerve entrapment at wrist. However, there is mild swelling and tenderness around the second metacarpal bone. Pain was aggravated during wrist and finger flexion.

DIAGNOSES

An electrodiagnostic study revealed CTS. She was advised to begin splinting the hand using a wrist brace and to undergo physiotherapy. After 2 weeks, the tingling sensation decreased slightly. However mild swelling and tenderness around the second metacarpal bone did not improve. Ultrasonography showed multiple echogenic foci. Magnetic resonance imaging (MRI) revealed a nodule at the proximal metacarpal level with synovial thickening, enhancement, and a calcified shadow close to the flexor tendon. After confirming the presence of an osseous nodule with synovial thickening, the patient underwent surgery INTERVENTIONS:: Carpal tunnel release and mass excision with synovectomy of the adjacent structures were performed. Histologically, the lesion was compatible with a diagnosis of SOC.

OUTCOME

The symptoms have improved.

LESSONS

CTS due to SOC on finger flexor tendon is rare but should be considered for possible etiology. Appropriate clinical examination, plain radiography, ultrasonography, and MRI will help physicians to diagnose this condition. In this paper, we report the successful diagnosis and treatment of CTS caused by SOC within the finger flexor tendon.

Predictive factors of the neuropathic pain in patients with carpal tunnel syndrome and its impact on patient activity

AIM

To determine the predictive factors of the neuropathic pain in patients with carpal tunnel syndrome (CTS), and the impact of such neuropathic pain on patient's activity.

METHODS

Douleur Neuropathique 4 questionnaire, Short Form-Brief Pain Inventory test and Boston Carpal Tunnel Syndrome Questionnaire were completed and results were stratified according neuropathic pain and work activity of the patients.

RESULTS

69 of 90 patients with CTS had neuropathic pain (76.7%). Increasing by one the scores of numbness/tingling, pain intensity and neurologic affectation of the electromyogram meant increasing 3.3-, 2.7- and 4.4-times the risk of neuropathic pain, respectively.

CONCLUSION

These results will be useful for a better neuropathic pain evaluation in patients with CTS, allowing the appropriate treatment.

Sensory profiles are comparable in patients with distal and proximal entrapment neuropathies, while the pain experience differs

OBJECTIVE

Distal and proximal entrapment neuropathies such as carpal tunnel syndrome (CTS) and cervical radiculopathy (CR) share similar etiologies. Experimental models suggest that, despite comparable etiology, pathomechanisms associated with injuries of the peripheral and central axon branches are distinct. This study therefore compared self-reported and elicited sensory profiles in patients with distal and proximal entrapment neuropathies.

METHODS

Patients with electrodiagnostically confirmed CTS (n = 103) and patients with CR (n = 23) were included in this study. A group of healthy participants served as controls (n = 39). Symptoms and sensory profiles were evaluated using quantitative sensory testing (QST) and a self-reported neuropathic pain questionnaire (painDETECT).

RESULTS

Both patient groups were characterized by a loss of function in thermal and mechanical detection in the main pain area and dermatome compared to healthy reference data (p < .001). There was no significant difference between patients with CTS and CR in pain and detection thresholds except for reduced vibration sense in the main pain area (p < .001) and reduced pressure pain sensitivity in the dermatome in patients with CR (p < .001). However, patients with CR reported higher pain intensities (p = .008), more severe pain attacks (p = .009) and evoked pain by light pressure (p = .002) compared to patients with CTS.

CONCLUSION

While QST profiles were similar between patients with CTS and CR, self-reported pain profiles differed and may suggest distinct underlying mechanisms in these patient cohorts.

Preoperative predictors of patient satisfaction after carpal tunnel release

BACKGROUND

We investigated preoperative factors among demographic and clinical characteristics, as well as psychological factors that influence postoperative patient satisfaction, with the goal of assisting preoperative patient consultation for CTR.

MATERIALS AND METHODS

We included 92 hands from 60 patients diagnosed with idiopathic carpal tunnel syndrome. We selected the following factors as possible preoperative predictors for patient satisfaction: age, sex, duration of symptoms, static two-point discrimination, the Semmes-Weinstein monofilament test, grip strength, electrophysiological category and scores for the Boston Carpal Tunnel Questionnaire, the Pain Anxiety Symptoms scale and the Center for the Epidemiological Study of Depression scale. We used a cumulative logit model with generalized estimation equations to identify the predictors of patient satisfaction after CTR.

RESULTS

Univariate analyses demonstrated significant correlations of patient satisfaction with age, preoperative grip power and preoperative CES-D. Multivariate analyses showed that age and preoperative CES-D scores were significantly correlated with patient satisfaction.

CONCLUSION

Age and depression level were preoperative predictors influencing satisfaction after CTR.

LEVELS OF EVIDENCE

IV.

Mucolipidosis type III, a series of adult patients

BACKGROUND

Mucolipidosis type III α/β or γ (MLIII) are rare autosomal recessive diseases, in which reduced activity of the enzyme UDP-N-acetyl glucosamine-1-phosphotransferase (GlcNAc-PTase) leads to intra-lysosomal accumulation of different substrates. Publications on the natural history of MLIII, especially the milder forms, are scarce. This study provides a detailed description of the disease characteristics and its natural course in adult patients with MLIII.

METHODS

In this retrospective chart study, the clinical, biochemical and molecular findings in adult patients with a confirmed diagnosis of MLIII from three treatment centres were collected.

RESULTS

Thirteen patients with MLIII were included in this study. Four patients (31%) were initially misdiagnosed with a type of mucopolysaccharidosis (MPS). Four patients (31%) had mild cognitive impairment. Six patients (46%) needed help with activities of daily living (ADL) or were wheelchair-dependent. All patients had dysostosis multiplex and progressive secondary osteoarthritis, characterised by cartilage destruction and bone lesions in multiple joints. All patients underwent multiple orthopaedic surgical interventions as early as the second or third decades of life, of which total hip replacement (THR) was the most common procedure (61% of patients). Carpal tunnel syndrome (CTS) was found in 12 patients (92%) and in eight patients (61%), CTS release was performed.

CONCLUSIONS

Severe skeletal abnormalities, resulting from abnormal bone development and severe progressive osteoarthritis, are the hallmark of MLIII, necessitating surgical orthopaedic interventions early in life. Future therapies for this disease should focus on improving cartilage and bone quality, preventing skeletal complications and improving mobility.