The relationship between benign joint hypermobility syndrome and carpal tunnel syndrome

Benign joint hypermobility syndrome (BJHS) is defined as the presence of musculoskeletal symptoms in persons with generalized joint laxity in the absence of systemic rheumatologic disease. There is an association between soft tissue rheumatism, entrapment neuropathies, and BJHS. The purpose of the study was to identify the relationship between BJHS and carpal tunnel syndrome (CTS). Ninety patients were included in the prospective controlled study. All selected participants were referred to our electrophysiological laboratory with clinical diagnosis of CTS. Subsequently, subjects were divided into two groups as group I and II. Group I included patients with CTS and group II had patients without CTS based on electrophysiological findings. All subjects were assessed for existing BJHS by using the Brighton 1998 criteria. Fifty-five patients were recruited into group I (CTS) and 35 subjects were in group II. The mean age in group I and II was 49.5 +/- 10.8 and 40 +/- 9.9 years, respectively. The subjects in group II were younger than those in group I (p < 0.05). The mean Beighton score was 2.04 +/- 2.7 and 1 +/- 1.68 in groups I and II, respectively. In patients with CTS, BJHS rate was markedly higher than those in patients without CTS with respect to Brighton 1998 criteria (p < 0.0001). There was a positive correlation between CTS and BJHS (r = 0.59, p = 0.0001). Consequently, we suggested that BJHS could be a predisposing factor for CTS or vice versa.     

尼麦角林治疗腕管综合征疗效分析

目的：观察尼麦角林治疗轻中度腕管综合征（CTS）的疗效。方法：将68例CTS患者随机分为2组,尼麦角林组给予尼麦角林联合皮质类固醇治疗,地巴唑组给予地巴唑联合皮质类固醇治疗,4、12周后观察临床疗效和神经电生理变化。结果：尼麦角林组治疗后4周症状严重程度评分（SSS）和功能评分（FSS）较治疗前明显改善（均P〈0．05）;12周时其效果更为明显（P〈0．05）,与地巴唑组比较,有统计学差异（P〈0．05）。神经电生理指标表现为不同程度的改善,其中尤其以环指正中、尺神经感觉潜伏期差值恢复最显著。结论：尼麦角林联合皮质类固醇能有效改善轻中度CTS临床症状和电生理指标,并取得持久的缓解。     

腕管综合征超声诊断的研究进展

腕管综合征是最常见的神经压迫病变。在过去的20年里,高频超声在腕管综合征的诊断中被认为是有效和可靠的。本文通过对腕管综合征的超声诊断指标及其准确性作一系统阐述,为未来研究提供理论依据和参考。     

Lifetime risk of symptomatic carpal tunnel syndrome in Type 1 diabetes.

AIMS: To determine the lifetime risk of developing symptomatic carpal tunnel syndrome (CTS) in subjects with Type 1 diabetes and to investigate the effect of glycaemic control, body mass index (BMI), gender and age of onset of diabetes. METHODS: One hundred and twenty-two consecutive subjects with Type 1 diabetes seen by a single investigator, over 1-year, were questioned about previous surgery for, or current symptoms of CTS. Those with current symptoms were referred for nerve conduction studies (NCS). Those with previous surgery and/or diagnostic NCS were classified as having CTS. Lifetime risk was calculated by the Kaplan-Meier method. RESULTS: Twenty six out of 122 patients had CTS, 18 of whom (69%) had undergone median nerve decompression surgery. The predicted lifetime risk of CTS reached 85% after 54 years of Type 1 diabetes (95% confidence interval: 72-97%). The duration of diabetes was greater in those who had developed CTS than in those who had not (29 vs. 19 years, P=0.0001). In those diagnosed with diabetes before the age of 20 there was a lag time of at least 19 years before the development of CTS, whereas patients with later onset of diabetes, began to develop CTS from as early as 5 years diabetes duration. There was no demonstrable effect of glycaemic control, obesity, gender or retinopathy on the appearance of CTS. CONCLUSION: The lifetime risk of developing symptomatic CTS with Type 1 diabetes is high, and is related to age and duration of diabetes, but not to the development of microvascular complications.     

Ultrasound-guided injection of carpal tunnel syndrome: A comparative study to blind injection

Background

Carpal tunnel syndrome (CTS) is the most common upper limb neuropathy with increasing incidence especially among females, having a high economic and social impact on patients. CTS can be treated either with conservative measures or surgically. Steroid injection, as a conservative treatment, could be carried out using anatomical landmarks or via ultra-sonographic guidance.

Emerging role of ultrasonography in the diagnosis of carpal tunnel syndrome: Relation to risk factors,clinical and electrodiagnostic severity

Carpal Tunnel Syndrome (CTS) is the most common compressive neuropathy and is a major cause of occupational disability. CTS diagnosis is based on clinical, neurophysiological and radiological examinations. Ultrasonography (US) is a time-saving, noninvasive and a cost-effective approach to confirm the diagnosis of CTS.Aim of the workTo assess the value of US in the diagnosis of idiopathic CTS compared to clinical assessment and electrodiagnostic studies. Considering the relation to the risk factors, clinical and electrodiagnostic grading of severity were well thought-out.Patients and methodsForty patients with idiopathic CTS (M/F: 34:6; age: 39.3 ± 7.1 years) along with 20 matched controls were recruited. Electrodiagnostic (EDx) grading of severity CTS was performed. US of the CSA (cross sectional area) of the median nerve at the distal wrist crease and at 12 cm proximal to this point in the forearm were measured to calculate the wrist-forearm median nerve CSA ratio. Results: There was a significant inverse relation between EDX-3 and EDX-5 severity grading scales (p < 0.001). There was a significant correlation between ultrasound CSA and EDx severity scales. US at the wrist CSA with EDX-3 (r = 0.69, p < 0.001), with EDX-5 (r = ?0.7, p < 0.001); wrist-forearm CSA ratio (WFR) with EDX-3 r = 0.51, p = 0.01) and with EDX-5 (r = ?0.56, p = 0.04) but not at the mid-forearm CSA with EDX-3 (r = 0.36,p0.07) and with EDX-5 (r = ?0.29, p = 0.15).ConclusionsUltrasonography is a sensitive and specific method in diagnosis of CTS compared to NCS. Therefore, US examination can be used as an alternative and/or adjuvant method in diagnosis of CTS for clinicians who do not have EMG-NCS equipment.     

Effect of Treatment with an Aldosereductase Inhibitor on Symptomatic Carpal Tunnel Syndrome in Type 2 Diabetes

The aim of this study was to test the efficacy of the aldose-reductase inhibitor Tolrestat in the treatment of carpal tunnel syndrome in Type 2 diabetic patients. Seventeen patients were treated with Tolrestat (200 mg daily for 12 months) clinical and neurophysiological evaluations were performed at baseline, 6 and 12 months; symptoms and blood glucose control were assessed at baseline, 2, 6, and 12 months. Thirteen Type 2 diabetic patients suffering from symptomatic carpal tunnel syndrome served as controls. Neurophysiological studies showed improvement in the sensory conduction velocity of the median nerve between forefinger and wrist (baseline 37.5 ± 4.3 vs 6 months 41.3 ± 5.7 ms^?1, p < 0.0005 and baseline vs 12 months 41.4 ± 8.2 ms^?1, p < 0.005) but not between wrist and elbow. The terminal latency index of the median nerve was unchanged. Paraesthesiae and pain improved in terms of intensity and frequency. Blood glucose control was not significantly changed. We conclude that treatment of this case series with Tolrestat appears to produce beneficial effect on the outcome of carpal tunnel syndrome in diabetic patients.     

A possible involvement of the carboxymethylation process in carpal tunnel syndrome in hemodialysis patients

A median motor nerve latency (DML) is generally prolonged in the carpal tunnel syndrome (CTS) of hemodialysis patients. Meanwhile, the advanced glycation process of proteins has been reported to be involved in the pathogenesis of the dialysis related amyloidosis. To investigate the role of carboxymethylation in dialysis related CTS, we measured a circulating carboxymethyllysine-hemoglobin (CML-Hb) level and nerve conduction velocity in 44 hemodialysis patients. The circulating CML-Hb level was 6.56 +/- 3.18 nmol CML/mg Hb, median motor nerve conduction velocity (NCV) was 49.8 +/- 4.64 m/s, median DML was 4.44 +/- 1.06 ms, and difference between median DML and ulnar DML (Delta DML) was 1.68 +/- 1.09 ms. Median and ulnar nerve NCV showed no correlation with circulating CML-Hb level. Both median DML and Delta DML were significantly correlated with CML-Hb (r = 0.429, P = 0.003, r = 0.472, P = 0.001). This study provided additional clinical evidence of an involvement of an advanced glycation process in the pathogenesis in CTS in hemodialysis patients.     

A novel approach of local corticosteroid injection for the treatment of carpal tunnel syndrome

The objective of the study was to compare the favorable response rate, time duration, and pain level of local corticosteroid injection using a novel approach for the treatment of carpal tunnel syndrome vs a classic approach. Patients with symptomatic carpal tunnel syndrome of less than 1-year duration were randomized for local corticosteroid injection using either the classic approach or a novel approach. In our approach (novel), we used a 29 gauge × 1/2-in. needle and a 1-ml insulin syringe containing 12 mg of methylprednisolone mixed with 0.15 ml of lidocaine 2%, and the site of the injection was 2–3 cm distal to the middle of wrist crease. In the classic approach, we used a 25 gauge × 3-cm needle and a 2-ml syringe injecting 35 mg of methylprednisolone mixed with 0.5 ml of lidocaine 2%, 3–4 cm proximal to the wrist crease and just ulnar to the tendon of the flexor carpi radialis muscle. Response rate was evaluated 1, 3, 6, and 12 weeks after the injection, and also the duration of time of the procedure and the level of pain using the visual analogue scale were compared between the two groups. Forty-two patients signed the consent form, and all of them completed the study [21 patients in the classic approach group (group 1) and 21 patients in the novel approach group (group 2)]. The favorable response rates were 100, 81, 71, and 57% in group 1 and 100, 71, 67, and 57% in group 2 after 1, 3, 6, and 12 weeks, respectively. There was no significant difference in the favorable response rate between the two groups (p=0.468, 95% CI=−12–31%, after 3 weeks). The average duration of time of the procedure in group 1 was 26.71±32.83 s compared to 8.48±1.123 s (p=0.021) in group 2. The average grade of pain expressed by the patients in group 1 was 4.38±1.523 compared to 3.62±1.071 in group 2 (p=0.065). In conclusion, local corticosteroid injection using the novel approach for the treatment of carpal tunnel syndrome is helpful, and the favorable response rates are comparable to those using the classic approach after 1, 3, 6, and 12 weeks. The novel approach is much less time consuming and is not more painful.     

Proteasome modulator 9 and carpal tunnel syndrome

Proteasome modulator 9 (PSMD9) is linked to type 2 diabetes (T2D).The author studied whether PSMD9 IVS3 + nt460 A > G, IVS3 + nt437 T > C and E197 are linked to carpal tunnel syndrome in T2D Italian families.Non-parametric linkage, linkage disequilibrium-based and independent SNPs-based linkage analyses were performed. The PSMD9 SNPs show linkage to carpal tunnel syndrome.     

Median neuropathy at the wrist as an early manifestation of diabetic neuropathy

Aims/Introduction

To elucidate the clinical significance of median neuropathy at the wrist (MN) in patients with diabetes.

Materials and Methods

In total, 340 patients with diabetes who were hospitalized for glycemic control were enrolled in the present study. The diagnoses of MN and diabetic polyneuropathy (DPN) were based on electrophysiological criteria. A total of 187 patients were divided into four subgroups: patients without MN or DPN; patients with MN without DPN; patients with MN and DPN; and patients with DPN without MN. Intergroup comparisons of clinical characteristics and results of nerve conduction studies were carried out.

Results

A total of 71 patients had neither MN nor DPN; 25 had MN, but no DPN; 55 had MN and DPN; and 36 had DPN, but no MN. In comparison with the MN and DPN group, the MN without DPN group included more patients in the early phase of diabetes (diagnosed within the past 5 years) and fewer patients with diabetic microangiopathy. Comparative median nerve conduction studies showed significantly lower motor and sensory nerve conduction velocities, longer F-wave latencies, and smaller sensory nerve action potentials in patients with MN and DPN than in those without DPN.

Conclusions

MN in patients with diabetes could be attributed to an impairment in axonal function at common entrapment sites, and could be used to identify an early manifestation of diabetic neuropathy.     

Recent advances in the management of diabetic distal symmetrical polyneuropathy

There is now little doubt that poor blood glucose control is an important risk factor for the development of diabetic peripheral neuropathy (DPN). Furthermore, traditional cardiovascular risk factors for macrovascular disease appear to be associated with an increased risk of DPN. The recently established International Expert Group on Diabetic Neuropathy has recommended new criteria for the diagnosis of DPN in the context of clinical and research settings. Studies in experimental diabetes examining the pathogenesis of DPN have identified a number of metabolic abnormalities including polyol pathway hyperactivity, increased advanced glycation end‐point formation, alterations in the protein kinase C beta pathway through diacylglycerol and oxidative stress. There is now strong evidence implicating nerve ischemia as the cause of DPN. Studies in human and animal models have shown reduced nerve perfusion and endoneurial hypoxia. These endoneurial microvascular changes strongly correlate with clinical severity and the degree of nerve‐fiber pathology. Unfortunately, many compounds that have been effective in animal models of neuropathy have not been successful in human diabetic neuropathy. The only compounds found to be efficacious in human diabetic neuropathy, and are in clinical use, are the anti‐oxidant, α‐lipoic acid and the aldose reductase inhibitor, epalrestat. Overall, the evidence emphasizes the importance of vascular dysfunction, driven by metabolic change, in the etiology of DPN, and highlights potential therapeutic approaches. Epidemiological data on diabetic painful neuropathic pain (DPNP) are limited. In one population‐based study, the prevalence of DPNP, as assessed by a structured questionnaire and examination, was estimated at 16%. It was notable that, of these patients, 12.5% had never reported symptoms to their doctor and 39% had never received treatment for their pain. Thus, despite being common, DPNP continues to be underdiagnosed and undertreated. Pharmacological treatment of DPNP include tricyclic compounds, serotonin noradrenalin reuptake inhibitors, the anti‐oxidant α‐lipoic acid, anticonvulsants, opiates, membrane stabilizers, topical capsaicin and so on. Management of the patient with DPNP must be tailored to individual requirements and will depend on the presence of other comorbidities. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2010.00083.x)     

The significance of carpal tunnel syndrome in transthyretin Val30Met familial amyloid polyneuropathy

Carpal tunnel syndrome (CTS) is frequently reported in association with amyloidosis. We determined the significance of CTS in transthyretin Val30Met-associated familial amyloid polyneuropathy (FAP ATTR Val30Met) by comparing the electrophysiological indices of the median and ulnar nerves in 58 patients. As a whole, sensory nerve conduction velocity (SCV) was slowed and distal motor latency (DML) was prolonged to a similar extent in the median and ulnar nerves in these patients. The extent of abnormalities in the median nerve was almost similar to that in the ulnar nerve in both early-onset cases from endemic foci and late-onset cases from non-endemic areas. In age-matched idiopathic patients with CTS (20 patients, 27 hands), the slowing of SCV and the prolongation of DML in the median nerve were significant, while the slowing of motor conduction velocity was much less compared to FAP ATTR Val30Met patients. Although concomitant lesions in the ulnar nerve entrapment site at the wrist cannot be excluded, these findings indicate that CTS is not the sole distinctive feature in the majority of FAP ATTR Val30Met patients. The electrophysiological abnormality at the distal portion of the median nerve may be a consequence of polyneuropathy rather than an entrapment injury.     

High incidence of carpal tunnel syndrome in diabetic patients after combined pancreas and kidney transplantation

Fifty-eight patients with long-standing type 1 (insulin-dependent) diabetes were studied prospectively after combined pancreas and kidney transplantation for a mean observation period of 47.9 months (range 17–116 months). Thirty-three per cent of these patients (19/58) developed carpal tunnel syndrome after a mean interval of 1.7 years (range 3 months–5 years). This rate is about twice that in type 1 diabetic patients. The manifestation of carpal tunnel syndrome was not significantly associated with worsening of diabetic polyneuropathy or with deterioration of kidney or pancreas function. In all but one patient symptoms improved without surgical intervention. This study suggests that patients after combined pancreas and kidney transplantation have an increased risk of carpal tunnel syndrome for which the etiology and pathophysiology are unknown. In most patients no surgical intervention is necessary.     

Bilateral carpal tunnel syndrome due to gouty tophi: conservative and surgical treatment in different hands of the same patient

Abstract

Gouty tophi are an uncommon cause of carpal tunnel syndrome. We describe a case of bilateral carpal tunnel syndrome due to gouty tophi. Gouty tophi in the right wrist developed slowly, but developed acutely in flexor tendons in the left wrist. Symptoms were numbness and finger movement dysfunction in both hands. The right hand was treated surgically, while the left hand was treated by medication. Both hands improved under a well-controlled serum uremic acid level.     

Diagnostic potential of high resolution ultrasound and nerve conduction study in patients with idiopathic carpal tunnel syndrome

Aim of the work

To evaluate the diagnostic utility of high resolution ultrasound in comparison to nerve conduction study (NCS) in patients with idiopathic carpal tunnel syndrome (CTS).

Predictors of rate of return to work after surgery for carpal tunnel syndrome

Objective . To evaluate the impact of patient demographics, clinical features, and job-related factors on the time until return to work after carpal tunnel release surgery. Methods . We employed a cross-sectional community-based study of 59 patients who had undergone carpal tunnel release surgery. Sociodemographic, clinical, and job-related characteristics and time to return to work were obtained by interview and from medical records. Exposure to ergonomic risk was derived from an independently validated job matrix. Time to return to work after surgery was analyzed by survival techniques. Results . Median time to return to work was 5 weeks. After adjustment, the relative rate (RR) of return to work per week after surgery was most strongly decreased by the receipt of workers' compensation, RR 0.2 (95% confidence interval [CI] 0.1–0.5), and by the exposure to bending and twisting of the hand prior to surgery, RR 0.7 (95% CI 0.5–0.9) per hour. Female gender was another predictor of decreased return to work, RR 0.5 (95% CI 0.3–0.8). Conclusions . Patients receiving workers' compensation, those exposed to higher levels of bending and twisting of their hands and wrists, and women were slower to return to work after carpal tunnel release surgery.