Endoscopic carpal tunnel release in patients receiving long-term hemodialysis

This study evaluated the clinical results of endoscopic carpal tunnel release in carpal tunnel syndrome caused by long-term hemodialysis and compared the results with that of idiopathic carpal tunnel syndrome. Operations were done in 32 patients (60 hands) with idiopathic carpal tunnel syndrome and in eight patients (15 hands) with carpal tunnel syndrome resulting from long-term hemodialysis. There was no significant difference in findings of preoperative evaluations and postoperative clinical results between the two groups, except for a difference with the patient satisfaction score with surgery on a visual analogue scale. The mean satisfaction score was 9.0 at 6 months, 9.3 at 1 year, and 9.5 at the 2-year followup in the group of patients with idiopathic carpal tunnel syndrome. However, in the group of patients with carpal tunnel syndrome resulting from long-term hemodialysis, the mean satisfaction score was 8.5 at 6 months, 8.2 at 1 year, and 6.5 at the 2-year followup. The score began to decrease at an average of 17.2 months after surgery. Long-term hemodialysis related carpal tunnel syndrome showed satisfactory short-term clinical results until approximately 1.5 years after the operation. After that time, the symptoms tended to deteriorate in 50% of the patients who received hemodialysis continuously.     

Does Carpal Tunnel Release Provide Long-Term Relief in Patients with Hemodialysis-Associated Carpal Tunnel Syndrome?

Background  

Carpal tunnel syndrome (CTS) is a common complication in patients receiving long-term hemodialysis. In the short-term however, these patients are less likely to have pain relief and restoration of function after carpal tunnel release. However, it is unclear whether patients who have release for hemodialysis-associated CTS have differing persisting relief of symptoms compared with patients with idiopathic CTS.     

Clinical course of the non-operated hand in patients with bilateral idiopathic carpal tunnel syndrome

PURPOSE: Patients with bilateral carpal tunnel syndrome (CTS) who had unilateral carpal tunnel surgery usually ask about the prognosis for the non-operated, opposite hand. In this study, we investigated the effects of unilateral carpal tunnel surgery on the clinical course of the non-operated, opposite hand in bilateral idiopathic CTS. METHODS: In this prospective study, only patients who had bilateral idiopathic CTS but had unilateral carpal tunnel surgery were included. Sixty-six patients were included in the study. All patients were women with the mean age 47 years and mean duration of symptoms 4 years. Forty-six surgeries were performed on right hands, and 20 surgeries performed on left hands. Forty-eight (73%) patients were housewives. Their non-operated, opposite hands were evaluated before and 6 months after unilateral surgery. The evaluations consisted of subjective symptoms and objective findings. Paired t-test and chi-square test were used for statistical analysis. RESULTS: There were no statistically significant differences between the means of symptom severity score, functional status score, power and pinch grip strength before and 6 months after unilateral surgery in the non-operated, opposite hands. There was no statistically significant differences among the percentages of the Tinel's sign, Phalen test, and electrophysiological changes before and 6 months after unilateral surgery on the non-operated, opposite hands. During the study period, 57 (86%) patients had surgery or intended to have surgery for their opposite hands. CONCLUSIONS: It seems that unilateral surgery for bilateral idiopathic CTS does not affect the clinical course of the non-operated, opposite hand. We recommend that each hand of patients with bilateral CTS be managed separately, based on their symptoms.     

Basal joint arthroplasty decreases carpal tunnel pressure

Background

There is a well-documented association between carpal tunnel syndrome (CTS) and thumb carpometacarpal (CMC) arthritis, and these conditions commonly coexist. We have observed that patients who have previously undergone thumb basal joint arthroplasty (BJA) seem rarely to present subsequently with CTS. Our hypothesis is that BJA decreases the pressure within the carpal tunnel.

Methods

Twenty-eight patients (6 with coexistent CTS) undergoing BJA were enrolled in the study. The pressure within the carpal tunnel immediately before and after BJA was measured using a commercially available pressure monitor device (Stryker STIC; Kalamazoo, MI). In patients with concomitant CTS undergoing both BJA and carpal tunnel release (CTR), the pressure was measured after BJA but prior to release of the transverse carpal ligament.

Results

The pressure within the carpal tunnel decreased after BJA in all patients. There were 3 patients with stage II arthritis, 15 patients with stage III arthritis, and 10 patients with stage IV arthritis. The mean pressure prior to BJA among all patients was 23.9 mmHg and decreased to 11.0 mmHg after BJA. Patients with concomitant CTS had a mean pre-BJA pressure of 26.5 mmHg, which decreased to 7.3 mmHg after BJA.

Conclusions

BJA decompresses the carpal tunnel and decreases the pressure within. In patients with concomitant CTS, the BJA alone (without additional release of the transverse carpal ligament) decreases the carpal tunnel pressure. Further study is warranted to determine the need for discrete release of the transverse carpal ligament in patients with CTS who are undergoing BJA.

Level of Evidence

Level II, diagnostic.     

Investigation of segmental carpal tunnel pressure in patients with idiopathic carpal tunnel syndrome--is it necessary to release the distal aponeurotic portion of the flexor retinaculum in endoscopic carpal tunnel release surgery?

Segmental carpal tunnel pressure was measured in 12 hands of 11 idiopathic carpal tunnel syndrome patients before and after two-portal endoscopic carpal tunnel release. We aimed to determine at which part of the carpal tunnel the median nerve could be compressed, and to evaluate whether carpal tunnel pressure could be reduced sufficiently at all segments of the carpal tunnel after the surgery. Pressure measurements were performed using a pressure guide wire. The site with the highest pressure corresponded to the area around the hamate hook; the pressure in the area distal to the flexor retinaculum could be pathogenically high (more than 30 mmHg) before the surgery. The two-portal endoscopic carpal tunnel release achieved sufficient pressure reduction in all segments of the carpal tunnel when the flexor retinaculum and the fibrous structure between the flexor retinaculum and the palmar aponeurosis were completely released.     

Evaluation of sensory function after median nerve decompression in carpal tunnel syndrome using the current perception threshold test

The recovery level for sensory function after carpal tunnel release for the treatment of idiopathic carpal tunnel syndrome (CTS) was assessed with the current perception threshold (CPT) test. Seventeen CTS patients (21 hands) were followed, and the CPTs at the index finger of each patient was measured preoperatively and at 1, 3, and 6 months postoperatively. After carpal tunnel release, there was significant recovery of CPT at all stimulation frequencies, indicating improvement of all sensory functions including sensations of temperature, pain, touch, and vibration.     

Carpal tunnel syndrome: a major complication in long-term hemodialysis patients

One hundred and forty-five patients on hemodialysis for periods of 1 month to 16 years were examined clinically for carpal tunnel syndrome (CTS). Typical symptoms and clinical manifestations of symptomatic CTS, either unilaterally or in both hands, were detected in 21 of these patients (15%). In contrast to the classic form of CTS, hemodialysis CTS in our patients was frequently accompanied by Raynaud's phenomenon of those digits supplied by the median nerve. A highly significant correlation was established between the incidence of CTS and the duration of dialysis (p less than 0.001). The association of CTS with analgesic nephropathy was significantly higher (52%) than with other kidney diseases (p less than 0.034). Immediate relief of pain was achieved after carpal tunnel release (11 releases) in 8 of the 21 patients. Sensory and motor function was gradually, but often only partially, restored. Unoperated CTS progressed to loss of sensory and motor function within 1 to 4 years after the onset of symptoms. CTS should be considered a major late complication in patients on chronic hemodialysis.     

Gliding resistance of flexor tendon associated with carpal tunnel pressure: A biomechanical cadaver study

The purpose of this study was to investigate the effect of carpal tunnel pressure on the gliding characteristics of flexor tendons within the carpal tunnel. Eight fresh human cadaver wrists and hands were used. A balloon was inserted into the carpal tunnel to elevate the pressure. The mean gliding resistance of the middle finger flexor digitorum superficialis tendon was measured with the following six conditions: (1) as a baseline, before balloon insertion; (2) balloon with 0 mmHg pressure; (3) 30 mmHg; (4) 60 mmHg; (5) 90 mmHg; (6) 120 mmHg. The gliding resistance of flexor tendon gradually increased as the carpal tunnel pressure was elevated. At pressures above 60 mmHg, the increase in gliding resistance became significant compared to the baseline condition. This study helps us to understand the relationship between carpal tunnel pressure, which is elevated in the patient with carpal tunnel syndrome (CTS) and tendon gliding resistance, which is a component of the work of flexion. These findings suggest that patients with CTS may have to expend more energy to accomplish specific motions, which may in turn affect symptoms of hand pain, weakness and fatigue, seen commonly in such patients. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:58–61, 2011     

Evaluation of hand function and symptom severity among patients after endoscopic carpal tunnel release]

The aim of the study was to evaluate function of hand and symptom severity after endoscopic carpal tunnel release. The examined material in this study comprises 45 patients (56) hands operated with single-portal endoscopic method. In order to evaluation outcomes of treatment Carpal Tunnel Syndrome Symptom Severity Scale (CTS SSS), Carpal Tunnel Syndrome Functional Status Scale (CTS FSS) and clinical examinations outcomes were used. Average results of preoperative questionnaires were equaled respectively: CTS SSS--2.9 and CTS FSS--2.8. Average results of postoperative questionnaires were equaled respectively: CTS SSS--1.5 and CTS FSS--1.7. Statistical analysis has shown significantly better results of CTS SSS and CTS FSS questionnaires, among patients with positive Tinel's Test and without thenar atrophy found before operation. Results of research based on questionnaires and clinical examinations, proved fast return of function of hand and decrease symptoms severity after endoscopic carpal tunnel release.     

Electromyographic evaluation after endoscopic carpal tunnel release in idiopathic carpal tunnel syndrome

The purpose of this study was to electromyographically evaluate results in patients with carpal tunnel syndrome (CTS) who underwent endoscopic carpal tunnel release (ECTR). The subjects were 26 patients with idiopathic CTS (37 hands) who were followed for at least 6 months after ECTR. To compare results informatively, hands were classified into four groups: those with normal distal motor latency (DML) and sensory conduction velocity (SCV) were classified as group A, those with normal DML and abnormal SCV as group B, those with an abnormal DML and normal SCV as group C, and those with abnormal DML and SCV as group D. All but one of the hands were classified as group D on the basis of preoperative electromyographic evaluation, while one was classified as group C. The mean preoperative obtainable DML and SCV values were 7.2 m and 27.3 m/s, respectively. Postoperatively, 12 hands were in group A, 8 hands in group B, 2 hands in group C, and 15 hands in group D. The mean DML and SCV values at final follow-up were 4.3 ms and 40.8 m/s, respectively. Of the 25 hands with muscle atrophy before surgery, 6 hands were in group A, 5 hands were in group B, 1 hand was in group C, and 13 hands were in group D at final follow-up. Thenar muscle atrophy and denervation potentials were present before surgery in 13 of the 15 hands classified as group D at the final follow-up. Received for publication on June 23, 1998; accepted on Oct. 30, 1998     

拇短展肌肌力定量测定在腕管综合征诊断中作用

目的探讨临床客观、量化的拇短展肌肌力评判方法。方法应用计算机化微型便携式肌力测定仪对101例(162只手)腕管综合征患者进行测定。其中女77例、男24例。年龄20～59岁。所有患者均于术前进行了肌力测定,其中62只手在术后6周再次测定。结果44%的患者具有拇短展肌肌力减弱,其不同性别间的差异具有极显著意义(P<0.001)。部分年龄组别间差异有显著性意义(P<0.05)。术前术后差异具极显著意义(P<0.001)。结论拇短展肌肌力定量测定是判断腕管综合征严重程度、评定疗效的一个良好的客观指标。     

Carpal tunnel release in patients with diabetes result in poorer outcome in long-term study

Background

The aim of this prospective study was to compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes mellitus with those with idiopathic CTS.

Methods

The results of surgical decompression of CTS in 27 patients with diabetes mellitus were compared with 42 patients with idiopathic CTS. All patients underwent surgical release of transverse carpal ligament by the mini-incision of palm technique. Patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status was evaluated before and 6 months and 10 years after surgery.

Results

After surgical release, all the patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. Six months after surgery, there was a significant improvement of symptomatic and functional BQ scores compared with preoperative state in both groups. Ten years after surgery, there was statistical difference in preoperative and postoperative 10th year functional BQ score between DM (?) and DM (+) (p < 0.01). DM status affected statistically functional BQ score between preoperative and postoperative 10th year.

Conclusion

Diabetes mellitus was a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes had worse surgical outcome compared with patients with idiopathic CTS in long-term follow-up.     

Carpal tunnel syndrome grading system in rheumatoid arthritis

The grading system of Hashizume and Hirooka for carpal tunnel syndrome (CTS) was modified to refine the system for surgical treatment selection for specific subsets of CTS in patients with rheumatoid arthritis (RA). The grading system uses clinical signs and symptoms of CTS, including pain indications, to identify surgical subsets of patients to facilitate treatment selection. Retrospective analysis of the system included radiographic and electromyographic findings. Twenty-nine hands of 21 adult patients with CTS in RA were graded in the current study. Eight hands with mild synovitis received conservative treatment only. Endoscopic carpal tunnel release (ECTR), using Okutsu's universal subcutaneous endoscopic system with a clear cannula, was performed in 11 hands with moderate synovitis. Open carpal tunnel release (OCTR) combined with flexor tenosynovectomy was performed in 9 hands with severe synovitis. One more hand required OCTR after ECTR when malignant RA was diagnosed. Clinical results, evaluated using Kelly's criteria, were: excellent in 19 hands, good in 5, fair in 4, and poor in the 1 patient with malignant RA. Clinical symptoms of CTS improved in all but the latter patient. Although the sample size in the current study is small, the results appear to warrant further study to determine the clinical utility of the grading system. Received: April 2, 2001 / Accepted: November 1, 2001     

Postoperative morphologic analysis of carpal tunnel syndrome using high-resolution ultrasonography

The authors evaluated the morphologic changes that follow division of the transverse carpal ligament in patients with carpal tunnel syndrome (CTS) using high-resolution ultrasonography. Ten patients, for a total of 20 hands, underwent high-resolution ultrasonographic studies before the operation and 8 months after the operation. They were all diagnosed with bilateral idiopathic CTS. The authors evaluated the configuration of the median nerve and carpal tunnel at 3 different levels of the wrist: the distal radiocarpal joint level, the pisiform level, and the hook of hamate level. The median nerve gained in thickness to a remarkable extent at 2 distal levels after the operation. The change in morphology of the carpal tunnel at these 2 distal levels was obvious, but the cross-sectional area of the carpal tunnel was increased significantly only at the hook of hamate level. The transverse diameters of the carpal tunnel were not significantly changed. As mentioned, the authors found that the median nerve gained significantly in volume at the distal part of the carpal tunnel postoperatively, and the volumetric increase in the carpal tunnel appears to have resulted from an anterior displacement of newly formed transverse carpal ligament, rather than from a widening of the bony carpal arch.     

Carpal tunnel syndrome in patients on long-term haemodialysis.

The purpose of this study was to describe the pathophysiology of carpal tunnel syndrome (CTS) in patients on long-term haemodialysis. We examined 110 patients, who had been having haemodialysis for chronic renal failure and had CTS, to clarify the clinical features and electrophysiological changes in peripheral nerves. There was a significant correlation between the incidence of CTS and the duration of haemodialysis. Compared with idiopathic CTS, CTS caused by long-term haemodialysis had relatively limited postoperative improvement. Symptoms recurred postoperatively in 11 patients (19%) of those with CTS caused by long-term haemodialysis. Electrophysiological measurements of sensory nerve conduction velocity showed that it was slower in distal segments of the median nerve in patients on haemodialysis compared with normal volunteers. Nerve conduction velocity in the carpal tunnel was significantly delayed (p < 0.05) in the patients with CTS on long-term haemodialysis. N9-13 interpeak latencies were significantly longer (p < 0.05) in subjects who had had haemodialysis for at least 10 years. All the patients with advanced destructive spondyloarthropathy had longer N9-13 interpeak latency. These results suggest that CTS in patients on long-term haemodialysis has its basis in neuropathy. The clinical course of CTS in these patients is different from that of patients with idiopathic CTS, because the neuropathy involves not only the carpal tunnel region, but also the proximal part of the median nerve both diffusely and progressively.     

Raynaud's phenomenon in idiopathic carpal tunnel syndrome: postoperative alteration in its prevalence

In a previous study the prevalence of Raynaud's phenomenon (RP) in patients with idiopathic carpal tunnel syndrome (CTS) was found to be 60% which is much higher than that in the general population. We undertook a further study of the same cohort of patients have both CTS and RP and who had an open release of the carpal tunnel, to observe the effects of the operation on RP. We observed whether the symptoms of RP improved, and repeated the cold provocation tests to see if the arterial pulse which was decreased before operation would recover. We rated the outcome as good when the patients showed both an improvement of the symptoms of RP and a normal pulse amplitude after exposure to cold, fair when the pulse amplitude recovered to more than two-thirds of that before exposure, and poor when cold hypersensitivity was persistent or showed the same degree of decreased pulse amplitude as observed before operation. Of the 18 patients with both conditions, ten (56%) had good and four (22%) fair results, with a mean recovery time of 4.2 months (6 weeks to 1 year) after operation. If the vasospasm seen in RP is an expression of vasomotor irritation in the carpal tunnel, these findings suggest that local compression of vasomotor fibres in the carpal tunnel can also be relieved by the release of this structure. Careful consideration, however, is still required in treating patients with both conditions since in some cases. RP may be superimposed or it may have other origins.     

Carpal tunnel syndrome with severe sensory deficit: endoscopic release in 18 cases

Carpal tunnel syndrome (CTS) with severe sensory deficit was treated with endoscopic carpal tunnel release in 18 hands of 16 consecutive patients (median age 72 (28-92) years). In all hands, preoperative 2-point discrimination (2-PD) exceeded 15 mm in the radial and ulnar sides of the pulps of at least 2 of the 3 radial digits. All patients underwent an independent evaluation and answered a questionnaire concerning 11 activities of daily living (ADL) preoperatively and 6 months postoperatively. Complete resolution or improvement in daytime numbness and tingling was reported in 12 of 17 hands, of night symptoms in 12 of 16 hands, and of pain in 10 of 11 hands. The median ADL score improved from 3.1 to 1.4 (on a 1- to 5-point scale). 13 of the 16 patients were satisfied with the outcome. Two-PD had normalized in 14 hands and improved in 2. The results indicate that endoscopic carpal tunnel release is effective in improving symptoms and function in patients with CTS and severe sensory deficit, and that the prognosis for sensory recovery is good.     

Trigger digits-associated carpal tunnel syndrome: relationship between carpal tunnel release and trigger digits.

Of 875 idiopathic carpal tunnel syndrome (CTS) cases, 101 (11.5%) required trigger digit release operations within three years before and/or after carpal tunnel release (CTR); these 101 cases were investigated, retrospectively. Trigger digit release (TDR) was performed most often after the CTR, especially within three months. Next most common was at the same time as the CTR. The TDR performance rate after CTR was 5.9%. The nerve conduction study (NCS) comparison between trigger digits-associated CTS and isolated CTS showed that pre-operative distal motor latency was significantly more delayed in trigger digits-associated CTS, while there was no evidence of any difference due to age or gender. The difference of operative method (open or endoscopic procedure) did not influence the incidence rate of trigger digits after the CTR. This study suggested that trigger digits-associated CTS has a previously developed wide-ranging narrowing of the flexor tendon sheath.     

Carpal tunnel syndrome with severe sensory deficit: Endoscopic release in 18 cases

Carpal tunnel syndrome (CTS) with severe sensory deficit was treated with endoscopic carpal tunnel release in 18 hands of 16 consecutive patients (median age 72 (28-92) years). In all hands, preoperative 2-point discrimination (2-PD) exceeded 15 mm in the radial and ulnar sides of the pulps of at least 2 of the 3 radial digits. All patients underwent an independent evaluation and answered a questionnaire concerning 11 activities of daily living (ADL) preoperatively and 6 months postoperatively. Complete resolution or improvement in daytime numbness and tingling was reported in 12 of 17 hands, of night symptoms in 12 of 16 hands, and of pain in 10 of 11 hands. The median ADL score improved from 3.1 to 1.4 (on a 1- to 5-point scale). 13 of the 16 patients were satisfied with the outcome. Two-PD had normalized in 14 hands and improved in 2. The results indicate that endoscopic carpal tunnel release is effective in improving symptoms and function in patients with CTS and severe sensory deficit, and that the prognosis for sensory recovery is good.     

Carpal tunnel syndrome with severe sensory deficit: Endoscopic release in 18 cases

Carpal tunnel syndrome (CTS) with severe sensory deficit was treated with endoscopic carpal tunnel release in 18 hands of 16 consecutive patients (median age 72 (28-92) years). In all hands, preoperative 2-point discrimination (2-PD) exceeded 15 mm in the radial and ulnar sides of the pulps of at least 2 of the 3 radial digits. All patients underwent an independent evaluation and answered a questionnaire concerning 11 activities of daily living (ADL) preoperatively and 6 months postoperatively. Complete resolution or improvement in daytime numbness and tingling was reported in 12 of 17 hands, of night symptoms in 12 of 16 hands, and of pain in 10 of 11 hands. The median ADL score improved from 3.1 to 1.4 (on a 1- to 5-point scale). 13 of the 16 patients were satisfied with the outcome. Two-PD had normalized in 14 hands and improved in 2. The results indicate that endoscopic carpal tunnel release is effective in improving symptoms and function in patients with CTS and severe sensory deficit, and that the prognosis for sensory recovery is good.