Is carpal tunnel syndrome present in acute stroke patients? An investigative study using clinical and imaging screening tools

Carpal tunnel syndrome (CTS) is known to develop post-stroke. Median nerve ultrasound (US) is an inexpensive, effective means of screening. In this prospective feasibility study, we compared the ability of the physical exam, the Boston Carpal Tunnel Questionnaire (BCTQ) and median nerve US to screen for carpal tunnel syndrome (CTS) within 72 hours of stroke onset. We enrolled 24 consecutive patients. Using US, 19 (79%, p = 0.0386) of the 24 patients screened positive for CTS on the paretic side and 20 (83%, p = 0.0042) on the nonparetic side. With clinical examination, only 11 out of 24 (46%) screened positive for CTS on the paretic side and 8 (33%) on the nonparetic side. The BCTQ did not predict CTS. US can be an effective screening tool post-stroke. Further research is needed to determine specificity and efficacy compared to electrodiagnostic testing in this population.     

A Double‐blind,Randomized, Prospective Study of Epidural Steroid Injection vs. The mild® Procedure in Patients with Symptomatic Lumbar Spinal Stenosis

Background: Epidural steroid injections (ESIs) are commonly used to treat low back pain, including symptomatic lumbar spinal stenosis (LSS). Reports on LSS treatment with ESIs have not differentiated between neurogenic claudication, which is believed to result from nerve root compression, and lumbar radicular pain, thought to be caused by inflammation. While there is overlap between these groups, the clinical relevance of ESI treatment cannot be generalized between these 2 distinct diseases with completely different pathophysiological causes. Methods: This was a double‐blind, randomized, prospective study of ESI vs. the mild procedure in patients with symptomatic LSS, conducted at a single pain management center. Patient reported outcome measures included Visual Analog Scale, Oswestry Disability Index, and Zurich Claudication Questionnaire (ZCQ) patient satisfaction. Results: Thirty‐eight patients were randomized into 2 treatment groups, 21 in mild and 17 in ESI. At 6‐ and 12‐week follow‐up, patients treated with mild reported significantly greater pain decrease over time (P < 0.0001), and significantly greater functional mobility improvement over time (P < 0.0018) than ESI patients. At week 6, mild ZCQ patient satisfaction score of 2.2 indicated a higher level of satisfaction than for ESI with a score of 2.8. In addition, 12‐week ZCQ satisfaction score was 1.8, demonstrating sustained near‐term satisfaction in the mild group. No major mild or ESI device or procedure‐related complications were reported. Conclusions: This study demonstrated that in LSS patients suffering with neurogenic claudication, mild provides statistically significantly better pain reduction and improved functional mobility vs. treatment with ESI.     

Lumbar spinal stenosis in a young individual as a result of ligamantum flavum ossification: A case report

INTRODUCTIONSymtomatic lumbar ligamantum flavum calcification is quite rare in the young age group.PRESENTATION OF CASEThe authors report a case of young adult with diagnosis of lumbar spinal stenosis, presenting with leg pain and neurological deficits. Computerized tomography (CT) scan and magnetic resonance (MR) imaging studies revealed ossification of the ligamantum flavum as the causative factor of the disease and the patient recovered completely after the decompressive operation.DISCUSSIONIt is emphasized that attention should be given to this rare etiological factor of lumbar spinal stenosis.CONCLUSIONComplete relief can be achieved with early and adequate surgery.     

Local injection versus surgery in carpal tunnel syndrome: Neurophysiologic outcomes of a randomized clinical trial

ObjectiveThe aim of our study was to characterize the neurophysiologic outcomes in a randomized clinical trial comparing local corticosteroid injection and decompressive surgery in idiopathic carpal tunnel syndrome.MethodsClinical and neurophysiologic assessments were done at baseline and 12 months after treatment. Four parameters were evaluated in the nerve conduction study (NCS): distal motor latency, motor amplitude, sensory conduction velocity and sensory amplitude. Statistic signification was established by the Student’s t test, independent and paired samples, and Mann–Whitney test. Repeated measures analysis of variance was used by the three domains of symptoms. Correlations between the changes showed in clinical parameters and those evidenced by electromyography were calculated by the Pearson’s test.ResultsBoth groups of therapy were comparable at baseline. In 95 wrists, a second NCS was done 12 months post-treatment. Although clinical outcome improved in a similar way in both groups, we found statistically significant improvement in three (distal motor latency, sensory conduction velocity and sensory amplitude) of four neurophysiologic parameters only in the surgery group, when compared to baseline values.ConclusionsAlthough local corticosteroid injection and decompressive surgery are clinically effective in reducing symptoms of carpal tunnel syndrome, only surgery results in an improvement of the neurophysiologic parameters, at 12-months follow-up.SignificanceOnly decompressive surgery allows resolution of neurophysiologic changes. The symptoms of the syndrome are resolved with corticosteroid injections.     

The value of remembered pre-operative quick disabilities of the arm,shoulder and hand (QuickDASH) scores

Abstract

It would be useful if it were possible for the patients to recreate their pre-operative QuickDASH scores in audits where this score had not been recorded before surgery. We assessed the accuracy of remembered pre-operative QuickDASH scores among 229 consecutive patients and the value of a previously developed algorithm for correcting these scores. Real pre-operative scores and remembered pre-operative scores were compared after a mean of 21?months. Furthermore, the scores of a subgroup of 79 patients with carpal tunnel syndrome, subacromial impingement, thumb basal joint arthrosis or Dupuytren’s contracture were corrected using an algorithm. The mean difference between remembered and real pre-operative scores for all patients showed heteroscedacity in the Bland–Altman plot. The scores of the 79 sub-analysis patients were homoscedastic. The mean difference between remembered and real pre-operative scores was 9 (SD 16, SEM 1.85). Correcting the scores of the sub-group patients using our algorithm decreased the variation only moderately. The remembered pre-operative score is too inaccurate to be useful in individual patients, also when using our algorithm. However, subtracting nine from the mean remembered pre-operative score in a group of patients with any of the above diagnoses gives the real pre-operative score within the 95% confidence interval of four above and four below the real score.     

The diagnostic accuracy of high-resolution ultrasound in screening for carpal tunnel syndrome and grading its severity is moderated by age

ObjectiveTo assess the effect of age on the accuracy of high-resolution ultrasound (HRUS) in the diagnosis and grading of carpal tunnel syndrome (CTS).MethodsPatients with symptoms and signs of CTS (N = 527 wrists) were evaluated using electrodiagnostic studies (EDx) for CTS diagnosis and grading. Median nerve cross-sectional areas at carpal tunnel inlet (CSA) and at forearm level were measured by HRUS and the ratio of these values was calculated (WFR). Healthy controls underwent identical testing (N = 122 wrists). HRUS accuracy was assessed against the EDx standard by Receiver Operator Characteristic (ROC) curve analysis.ResultsIn patients >65 y with moderate and severe CTS, disease-related increases in CSA and WFR were negatively correlated with increasing age. Subjects were grouped by age into younger (<65 y) and older (≥65 y). The c-statistics for CSA and WFR respectively were: For CTS diagnosis, younger group: 0.94 and 0.96 (excellent); older group: 0.85 and 0.86 (satisfactory). For CTS grading, younger group: differentiating mild CTS from controls: 0.90 and 0.92 (excellent); mild from moderate: 0.79 and 0.74 (satisfactory); moderate from severe: 0.82 and 0.78 (satisfactory). For CTS grading, older group: differentiating mild CTS from controls: 0.83 and 0.83 (satisfactory); mild from moderate: 0.53 and 0.61 (poor); moderate from severe: 0.65 and 0.53 (poor).ConclusionsFor subjects aged <65 y, HRUS accuracy is excellent in CTS diagnosis and satisfactory in grading. For older subjects, accuracy is satisfactory in diagnosis but not in grading.SignificanceHRUS for CTS has diagnostic limitations selectively in older individuals.