Flexor Tenosynovectomy for Recurrent Carpal Tunnel Syndrome: A Retrospective Case Series of 108 Hands

Background: The etiology of recurrent carpal tunnel syndrome (CTS) is unclear, and outcomes following secondary surgery in this demographic have been poorer than primary surgery. Fibrosis and hypertrophy have been identified in the flexor tenosynovium in these patients. The authors use flexor tenosynovectomy (FTS) for recurrent CTS after primary carpal tunnel release and present a review of these patients. Methods: A retrospective chart review was performed of 108 cases of FTS for recurrent CTS from 1995 to 2015 by 4 attending surgeons at one institution. Demographic information, symptoms, and outcomes were among the data recorded. A phone survey was conducted on available patients where the shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) and satisfaction were assessed. Results: Average office follow-up was 12 months. Average age was 57.5 years. A total of 104 (96%) reported symptom improvement and 48 (44%) reported complete symptom resolution. Forty patients were available for long-term follow-up at an average 6.75 years postoperatively via phone interview. Average QuickDASH score was 31.2 in these patients. Thirty-six (90%) of 40 patients were initially satisfied at last office visit, and 31 (78%) of 40 were satisfied at average 6.9 years, a maintenance of satisfaction of 86%. Satisfied patients were older (58 years) than unsatisfied patients (51 years). Conclusion: Both long-term satisfaction and QuickDASH scores in our cohort are consistent with or better than published results from nerve-shielding procedures. The authors believe a decrease in both carpal tunnel volume and potential adhesions of fibrotic or inflammatory synovium contributes to the benefits of this procedure. This remains our procedure of choice for recurrent CTS.     

Accuracy of Surgeon Diagnosis in Predicting Carpal Tunnel Syndrome

Background: The utility of electrodiagnostic studies (EDX) continues to be a point of debate in the diagnosis of carpal tunnel syndrome (CTS). If surgeons can predict the results of EDX with high accuracy, it may suggest that ordering the test is unnecessary from a diagnostic standpoint. Methods: Two surgeons with subspecialty training in hand surgery were asked to classify hands into “definitely having or not having CTS” or into an “unclear category” when presented with patients having a chief complaint of hand paresthesias. Clinical diagnosis was compared against EDX, ordered after the initial patient visit, as the reference standard. Results: Of the 175 hands, 111 hands were predicted to have CTS, 37 hands were predicted not to have CTS, and 27 hands had an unclear diagnosis. Overall surgeon accuracy was 86% (124/148). Accuracy was improved when subdivided by a positive prediction of CTS (88%) compared with a negative prediction of CTS (70%) (P = .03). Sensitivity was 90% and specificity was 67%. The senior surgeon had a higher accuracy at 90% than the more junior surgeon at 74% (P = .02). Conclusions: Surgeons with sub-specialty training in hand surgery are able to accurately diagnose CTS without EDX. Surgeon experience is important and resulted in a higher accuracy in predicting EDX results.     

The Sensitivity and Specificity of Nerve Conduction Studies for Diagnosis of Carpal Tunnel Syndrome: A Systematic Review

Background: The utility of nerve conduction studies (NCS) for diagnosis of carpal tunnel syndrome (CTS) has continued to be a subject of debate. Proponents of NCS assume a high sensitivity and specificity; however, many are unaware of the actual literature on this topic and the cutoff values commonly used for diagnosis. The purpose of this systematic review of the literature is to report the sensitivity and specificity of NCS for diagnosis of CTS in various studies. Methods: A literature review of PubMed and EMBASE databases was performed for all articles on NCS for diagnosis of CTS. The outcome of interest was the sensitivity and/or specificity of the NCS distal motor latency (DML) or distal sensory latency (DSL) cutoff value used to diagnose CTS in each study. Results: A total of 3066 total articles were screened and 21 were included in the review after assessment by two independent reviewers. The mean cut-off value for DSL was 3.37 ms (range 2.8-4 ms) and the mean cutoff value for DML was 4.28 ms (range 3.8-4.6 ms). Weighted mean DSL sensitivity was 73.4% and weighted mean DSL specificity was 93.6%. Weighted mean DML sensitivity was 56.2% and weighted mean DML specificity was 95.8%. Conclusions: There is significant variation in the cutoff values used for both DSL and DML. The wide range of cut-off values makes it difficult to interpret the literature, and there is a lack of high-quality studies with control groups using a priori cut-off values for diagnosis.     

Compression neuritis of the ulnar nerve treated with simple decompression

The purpose of this investigation was to test the hypothesis submitted by Osborne (1957), which proposed that the symptoms of compression ulnar neuritis, in most cases, result from compression on the ulnar nerve at the proximal border of the aponeurosis of the flexor carpi ulnaris muscle. Thirty-two simple decompression operations were performed on 31 patients, diagnosed as suffering from compression neuritis of the ulnar nerve. They were subsequently examined over a period of 5 years. Relief from symptoms was achieved in 28 cases, whilst four patients derived no improvement from the operation. Three of the four unsuccessful cases were judged to have been incorrectly diagnosed and were not suffering from compression of the ulnar nerve in the elbow. A second operation was required in two patients, in one a second decompression and in the other anteposition. No surgical or post-surgical complications occurred.     

A Randomized Controlled Study of Contrast Baths on Patients with Carpal Tunnel Syndrome

Study DesignRandomized clinical trial. Introduction: Contrast baths are a treatment modality commonly used in hand clinics. Yet the benefits of contrast baths have been poorly substantiated. Contrast baths have been suggested for the purposes of reducing hand volume, alleviating pain, and decreasing stiffness in affected extremities.Purpose of the StudyTo determine the effects of specific contrast bath protocols on hand volume in patients diagnosed with Carpal Tunnel Syndrome.MethodsStudy participants were randomly assigned to one of three treatment group protocols—contrast baths with exercise, contrast baths without exercise, and an exercise-only control treatment group. Study participants were evaluated with hand volumetry, before and after treatment at two different data collection periods—pre- and postoperatively.ResultsData were gathered on 58 participants before Carpal Tunnel Release surgery and on 56 participants after Carpal Tunnel Release surgery, for a total of 114 treatments. The changes in hand volume (the after treatment volume minus the before treatment volume) were analyzed using one-way and multi-way analysis of variance (ANOVA). Although all three treatments resulted in a slight increase in hand volume both pre- and postsurgery, the increase was not clinically significant with regard to hand volumes. Also no significant differences were noted among the three treatments. Specifically, the ANOVA for presurgery differences among treatments had F = 0.155 (2 and 55 df), p = 0.857. The ANOVA for postsurgery difference among treatments had F = 0.544 (2 and 53 df), p = 0.584.ConclusionsThe use of contrast bath treatment has no significant effect on increase or decrease of hand volume in Carpal Tunnel Syndrome patients, pre- and/or postoperatively.Level of evidence1B.     

Processus Supracondyloidea Humeri with Concomitant Compression of the Median Nerve and the Ulnar Nerve

Compression of the median nerve and the ulnar nerve due to the anatomical anomaly processus supracondyloidea humeri is a rare condition. a case of combined median and ulnar nerve compression is described. Diagnostics and treatment are discussed in the light of the present case history and those described in the literature. The conclusion is that the treatment should be subperiosteal resection of the process together with the origin of the pronator teres muscle.