Clinical diagnosis of carpal tunnel syndrome: old tests-new concepts

BackgroundThe diagnosis of carpal tunnel syndrome (CTS) continues to be neurophysiologically and clinically controversial. Earlier data concluding that the higher prevalence of persons with symptoms suggestive of CTS but without evidence of median mononeuropathy highlights the need for a better understanding of the underlying pathophysiology and natural history of CTS to provide a less empirical foundation for diagnosis and clinical management.ObjectiveTo examine the relationship between the clinical manifestations of CTS with the outcome of the diagnostic tools (nerve conduction tests and ultrasonography), and its implication for clinical practice.MethodsTwo-hundred and thirty-two patients (69 male and 163 female, ages ranging between 20 and 91 years) with CTS manifestations and 182 controls were included in this study. Diagnosis of CTS was based on the American Academy of Neurology clinical diagnostic criteria. All patients and controls completed a patient oriented questionnaire, were subjected to clinical testing for provocative tests for carpal tunnel syndrome (Tinel's, Phalen's, Reverse Phalen's and carpal tunnel compression tests), blood check for secondary causes of carpal tunnel syndrome, nerve conduction testing as well ultrasonographic assessment of the carpal tunnel and median nerve.ResultsOne-hundred and seventy-seven out of 232 (76.3%) had abnormal nerve conduction studies. Forearm symptoms and tenosynovitis confirmed by US examination were found in 51.3% of cases. No significant difference was found on comparing anthropometric measures in the affected hands to the control group hands. A higher prevalence of positive Phalen's and CT compression were found in patients suffering from tenosynovitis regardless of their nerve conduction study results. Sensitivity of Tinel's, Phalen's, Reverse Phalen's and carpal tunnel compression tests was higher for the diagnosis of tenosynovitis than for the diagnosis of CTS (Tinel, 46% vs. 30%; Phalen's, 92% vs. 47%; Reverse Phalen's, 75% vs. 42%; carpal tunnel compression test, 95% vs. 46%). Similarly, higher specificity of these tests was found with tenosynovitis than CTS.ConclusionThe results of this study revealed that Tinel's, Phalen's, Reverse Phalen's and carpal tunnel compression tests are more sensitive, as well as being specific tests for the diagnosis of tenosynovitis of the flexor muscles of the hand, rather than being specific tests for carpal tunnel syndrome and can be used as an indicator for medical management of the condition.     

A clinical questionnaire for the diagnosis of carpal tunnel syndrome

This prospective study compared the sensitivities of a scored questionnaire and electrophysiological examination in the diagnosis of carpal tunnel syndrome. Patients were assessed by a hand surgeon using a scored questionnaire, and then underwent an electrophysiological assessment by an experienced neurophysiologist (blinded to the questionnaire results). Patients diagnosed as having carpal tunnel syndrome by either the questionnaire, the electrophysiological examination or both underwent decompression. Symptom relief was taken as the "gold standard" for true carpal tunnel syndrome. The results showed a sensitivity of 85% for the scored questionnaire and 92% for nerve conduction studies with a positive predictive value of 90% for the scored questionnaire and 92% for nerve conduction studies. The authors recommend that a scored questionnaire can replace nerve conduction studies in the initial assessment of whether patients presenting with dysaesthesiae in the fingers should undergo surgery. This will give major time, personnel and cost benefits.     

腕管综合征复发7例分析

目的 总结7例小切口手术治疗腕管综合征复发病例的诊治过程,为临床提供治疗经验.方法 2012年1月至2019年12月,对已在外院经临床和电生理确诊为腕管综合征且行小切口手术治疗后复发的7例病人进行二次常规手术切口治疗.术中探查发现7例腕管内均有白色粉末状物沉积,给予腕管内病灶清除及彻底松解正中神经.根据顾玉东推荐的腕管...     

Carpal tunnel syndrome treated with guided brain plasticity: a randomised,controlled study

Introduction: Guided plasticity, induced by cutaneous forearm anaesthesia, improves hand sensibility in patients with nerve injury and vibration-induced neuropathy. This study investigated whether patients with carpal tunnel syndrome (CTS) would benefit from cutaneous forearm anaesthesia.

Methods: Seventy patients with clinical and electroneurography-verified CTS were randomised to sensory training combined with either an anaesthetic cream (EMLA^®) (n?=?34) or a placebo cream (n?=?36) on the volar part of the forearm. The treatment was repeated at increasing intervals over 8 weeks. The primary outcome was the Boston carpal tunnel questionnaire (BCTQ) symptom severity scale after 8 weeks. Secondary outcomes included activity limitations, sensory function, and nerve conduction. This study compared the longitudinal changes between the two groups, and with correction for multiple comparisons it also compared the longitudinal change within the groups.

Results: There were no significant differences in primary or secondary outcomes between the groups. However, the BCTQ symptom severity scale improved significantly within the EMLA^® group over the 8-week period (p?=?0.001). Apart from this, no significant improvements in activity limitations, sensory function, or nerve conduction were seen in the two groups compared to baseline. Altogether, 47% of patients in the EMLA^® group and 61% in the placebo group had been operated on with carpal tunnel release by 12 months.

Conclusion: An 8-week treatment protocol with cutaneous forearm anaesthesia to guide brain plasticity gave no significant subjective or objective improvements in hand function compared to placebo.     

The outcome of carpal tunnel decompression in elderly patients

PURPOSE: To determine the outcomes of carpal tunnel decompression in elderly patients and whether outcomes can be predicted by the severity of presurgical nerve conduction study results. METHODS: We performed a retrospective study of all patients over 70 years of age who had elective carpal tunnel release at Dunedin Hospital between April 1999 and April 2002 with a minimum of 1-year follow-up evaluation. A grading system for presurgical nerve conduction studies was formulated that scored patients from 1 to 6 according to severity. Patients were evaluated by a mailed questionnaire (Symptom Severity Score) with follow-up telephone calls to nonresponders. RESULTS: Eighty-three carpal tunnel release procedures performed in 70 patients were included in the study. Eighty percent had marked to severe neurophysiologic changes (grades 4-6). The median postsurgical Symptom Severity Score was 1.3 (inter-quartile range, 1.1-1.7). Patients expressed satisfaction with the outcome of the surgery in 78 of 83 cases (94%). There was a significant relationship between presurgical nerve conduction grade and postsurgical Symptom Severity Score. CONCLUSIONS: This study shows that elderly patients have low postsurgical symptom scores and express high levels of satisfaction after surgery for carpal tunnel syndrome. There was a significant relationship between severity of neurophysiologic abnormalities and a higher Symptom Severity Score after surgery. Severe abnormality, however, should not exclude elderly patients from surgery.     

Effective self-stretching of carpal ligament for the treatment of carpal tunnel syndrome: A double-blinded randomized controlled study

IntroductionCarpal tunnel syndrome (CTS) is the most common nerve entrapment syndrome worldwide. There are limited studies on the effectiveness of carpal ligament stretching on symptomatic and electrophysiologic outcomes.Purpose of the StudyThe purpose of this study was to evaluate the effect of self-myofascial stretching of the carpal ligament on symptom outcomes and nerve conduction findings in persons with CTS.Study DesignThis is a prospective, double-blinded, randomized, placebo-controlled trial.MethodsEighty-three participants diagnosed with median mononeuropathy across the wrist by nerve conduction study were randomized 1:1 to sham treatment or self-carpal ligament stretching. Participants were instructed to perform the self-treatment four times a day for six weeks. Seventeen participants in the sham treatment group and 19 participants in the carpal ligament stretching group completed the study. Pre- and post-treatment outcome measures included subjective complaints, strength, nerve conduction findings, and functional scores.ResultsGroups were balanced on age, sex, hand dominance, symptom duration, length of treatment, presence of nocturnal symptoms, and compliance with treatment. Even though the ANOVA analyses were inconclusive about group differences, explorative post hoc analyses revealed significant improvements in numbness (P = .011, Cohen's d = .53), tingling (P = .007, Cohen's d = .60), pinch strength (P = .007, Cohen's d = −.58), and symptom severity scale (P = .007, Cohen's d = .69) for the treatment group only.ConclusionsThe myofascial stretching of the carpal ligament showed statistically significant symptom improvement in persons with CTS. Larger comparative studies that include other modalities such as splinting should be performed to confirm the effectiveness of this treatment option.     

Carpal tunnel syndrome caused by a giant cell tumour of the flexor tendon sheath

Abstract

A 76-year-old woman developed right carpal tunnel syndrome after being conservatively treated for tenosynovitis of the flexor tendons with associated mild carpal tunnel syndrome. A magnetic resonance imaging scan showed a tumour in the carpal tunnel. Re-exploration showed that the median nerve was being compressed by a giant cell tumour of the flexor tendon sheaths. Appropriate imaging is advised in patients with additional findings (such as swelling) or in patients with secondary carpal tunnel syndrome and incomplete response to conservative treatment, to exclude a space-occupying lesion.     

Double crush syndrome: Epidemiology,diagnosis, and treatment results

BackgroundDouble Crush Syndrome (DCS) is a clinical condition that involves multiple compression sites along a single peripheral nerve. The present study aims to describe the epidemiology of DCS and surgical results.MethodsA retrospective observational analytic study included patients with clinical diagnosis of cervical radiculopathy and carpal tunnel syndrome who underwent surgery between January 2009 and January 2019. General demographic characteristics were noted, and 3 groups were distinguished: spinal surgery, carpal tunnel release, and bimodal decompression (BD); statistical differences were analyzed between them.ResultsThe sample comprised 32 patients. DCS prevalence was 10.29%. Mean age at presentation was 59.25 ± 10.98 years. There was female predominance (75%). Paresthesia was the main symptom (65.6%). Post-surgical results of BD showed significant improvement in sensory nerve conduction velocity, motor nerve conduction velocity (both P = 0.008), and disability on Douleur Neuropathique 4 questions, Neck Disability Index, and Boston Carpal Tunnel Questionnaire (P = 0.001, 0.004, 0.008, respectively).ConclusionsDiagnosis and management of DCS are a challenge. It is necessary to determine the site with maximal compression and risk of complications to decide on treatment. If first-line surgery is adequate, proximal and distal symptomatology can be improved. To maximize success, we recommend BD, according to the present results.     

Platelet-rich plasma versus corticosteroid injections for carpal tunnel syndrome

Background: Platelet-rich plasma therapy has the potential to promote peripheral nerve regeneration through the autologous supply of growth factors. Therefore, this study aimed to compare the effects of platelet-rich plasma injections with the effects of corticosteroid injections in the treatment of carpal tunnel syndrome.

Methods: In total, 40 patients with mild carpal tunnel syndrome were equally divided into two groups. Nerve conduction studies were carried out, and the Boston Carpal Tunnel Questionnaire was administered to both groups before treatment. One group of patients received platelet-rich plasma injections, and the patients in the other group received corticosteroid injections into the carpal tunnel. The patients were followed for 6 months. After 3 and 6 months, the nerve conduction studies and the Boston Carpal Tunnel Questionnaire were repeated.

Results: Although distal motor latencies did not change in either of the groups during the follow-up period, improvements in sensory nerve conduction were recorded after 3 months in both groups. However, there was no significant difference between the groups in the nerve conduction studies. In the Boston Carpal Tunnel Questionnaire, both the symptom severity score and the functional capacity score of the platelet-rich plasma group were significantly better than those of the corticosteroid group after 3 months, although there were no significant differences after 6 months.

Conclusions: Platelet-rich plasma injections may be considered for the temporary symptomatic relief of mild carpal tunnel syndrome.     

Clinical management of carpal tunnel syndrome in patients with long-term sequelae of poliomyelitis

Thirty-three patients with long-term sequelae of poliomyelitis with a diagnosis of carpal tunnel syndrome established by either abnormal nerve conduction studies or previous carpal tunnel surgery were surveyed. There was no significant long-term resolution of symptoms in the patients who had surgery (n = 9) or were currently using wrist orthoses (n = 11) compared with patients without such treatment (n = 13). In patients who used a single cane or those who used crutches (N = 10), there was a direct correlation between the hand holding the cane or crutch and the hand in which carpal tunnel syndrome developed. The chronic use of cane and crutch predisposes these patients to development of carpal tunnel syndrome, and caution should be used when considering wrist surgery.     

Age delays the recovery of distal motor latency after carpal tunnel syndrome surgery

Background

Studies have shown slow healing of peripheral nerve injury in elderly patients. Carpal tunnel syndrome (CTS) is the most frequent compressive mononeuropathy, affecting mostly older people and females. Few studies have assessed electrophysiological differences between younger and older patients. We aimed to evaluate age-dependent differences in electrophysiological parameters preoperatively and postoperatively over a 100-day postoperative period.

Method

This retrospective study included 258 hands of patients who underwent conventional open-technique carpal tunnel syndrome surgery. Patients with paresthesia in the median nerve distribution or with impaired sensation or abnormal findings in sensory and motor median nerve conduction studies were enrolled. The age dependence of the preoperative values of distal motor latency, amplitude of the compound motor action potential and sensory conduction velocity was estimated using regression analysis.

Results

Statistically significant age dependence was found for the preoperative distal motor latency, compound motor action potential, amplitude and sensory conduction velocity. The repair of segmental demyelination was nearly twice as slow in the older group, at a 5 % significance level, even when comparing groups with the same preoperative distal motor latency.

Conclusions

Analysis of preoperative nerve conduction parameters indicates that surgery for carpal tunnel syndrome is performed later in older patients.     

Assessment of outcome of carpal tunnel syndrome: a comparison of electrophysiological findings and a self-administered Boston questionnaire

The relationship between nerve conduction studies and the self-administered Boston Questionnaire that measures the severity of symptoms and functional status in carpal tunnel syndrome was assessed in 44 patients with idiopathic carpal tunnel syndrome. The patients were examined preoperatively and 3 and 6 months postoperatively. Although both the clinical outcome and electrophysiological findings improved significantly after surgery, we observed no correlation between improvements in nerve conduction and the questionnaire scores.     

Treatment of carpal tunnel syndrome by low-level laser versus open carpal tunnel release

Carpal tunnel syndrome (CTS) is an entrapment neuropathy of the median nerve at the wrist. It is one of the most common peripheral nerve disorders. The cause of idiopathic CTS remains unclear. The diagnosis of CTS is still mainly clinical. Open carpal tunnel release is the standard treatment. The present study was conducted to evaluate the effectiveness of low level laser treatment (LLLT) for CTS in comparison to the standard open carpal tunnel release surgery. Out of 54 patients, 60 symptomatic hands complaining of CTS were divided into two equal groups. Group A, was subjected to LLLT by Helium Neon (He–Ne) laser (632.8 nm), whereas group B was treated by the open approach for carpal tunnel release. The patients were evaluated clinically and by nerve conduction studies (NCSs) about 6 months after the treatment. LLLT showed overall significant results but at a lower level in relation to surgery. LLLT showed significant outcomes in all parameters of subjective complaints (p ≤ 0.01) except for muscle weakness. Moreover, LLLT showed significant results in all parameters of objective findings (p ≤ 0.01) except for thenar atrophy. However, NCSs expressed the same statistical significance (p ≤ 0.01) after the treatment by both modalities. LLLT has proven to be an effective and noninvasive treatment modality for CTS especially for early and mild-to-moderate cases when pain is the main presenting symptom. However, surgery could be preserved for advanced and chronic cases. Refinement of laser tools and introduction of other wavelengths could make LLLT for CTS treatment a field for further investigations.     

Magnetic resonance neurography studies of the median nerve before and after carpal tunnel decompression

OBJECT: Recently developed novel MR protocols called MR neurography, which feature conspicuity for nerve, have been shown to demonstrate signal change and altered median nerve configuration in patients with median nerve compression. The postoperative course following median nerve decompression can be problematic, with persistent symptoms and abnormal results on electrophysiological studies for some months, despite successful surgical decompression. The authors undertook a prospective study in patients with carpal tunnel syndrome, correlating the clinical, electrophysiological, and MR neurography findings before and 3 months after surgery. METHODS: Thirty patients and eight control volunteers were recruited to the study. The MR neurography consisted of axial and sagittal images (TR = 2000 msec, TE = 60 msec) obtained using a temporomandibular surface coil, fat saturation, and flow suppression. Maximum intensity projection images were used to follow the median nerve through the carpal tunnel in the sagittal plane. Magnetic resonance neurography in patients with carpal tunnel syndrome demonstrated proximal swelling (p < 0.001) and high signal change in the nerve, together with increased flattening ratios (p < 0.001) and loss of nerve signal in the distal carpal tunnel (p < 0.05). Sagittal images were very effective in precisely demonstrating the site and severity of nerve compression. After surgery, division of the flexor retinaculum could be demonstrated in all cases. Changes in nerve configuration, including increased cross-sectional area, and reduced flattening ratios (p < 0.001) were seen in all patients. In many cases restoration of the T. signal intensity toward that of controls was seen in the median nerve in the distal carpal tunnel. Sagittal images were excellent in demonstrating expansion of the nerve at the site of surgical decompression. CONCLUSIONS: In this study the authors suggest that MR neurography is an effective means of both confirming compression of the median nerve and its successful surgical decompression in patients with carpal tunnel syndrome. This modality may prove useful in the assessment of unconfirmed or complex cases of carpal tunnel syndrome both before and after surgery.     

Disability outcomes in a worker's compensation population: surgical versus nonsurgical treatment of carpal tunnel syndrome

A retrospective record review of patients with occupational carpal tunnel syndrome, nerve conduction velocity studies, and a closed Workers' Compensation case was undertaken to compare the outcome of surgical versus nonsurgical treatment with respect to disability and return to work status. Between January 1, 1991, and December 31, 1993, 182 patients who met the inclusion criteria were identified. Surgical release of the carpal tunnel was performed in 57% of patients and the other 43% were treated conservatively. Overall, 82% of patients returned to full work status, whereas 18% had duty modifications. Surgical treatment decreased the rate of duty modifications and disability ratings compared with nonsurgical treatment and reduced the odds of incurring disability. Severity of carpal tunnel syndrome was also a significant factor affecting disability. Despite the generally held belief that the outcome of treatment of occupational carpal tunnel syndrome is poor, the present study shows that both surgical and nonsurgical treatment is effective. However, patients treated with surgery had decreased disability when compared with those who were treated conservatively.     

Correlation of high-resolution ultrasonographic findings with the clinical symptoms and electrodiagnostic data in carpal tunnel syndrome

There are several different imaging methods that are helpful in the diagnosis of carpal tunnel syndrome, including traditional radiography, computed tomography (CT), and magnetic resonance imaging (MRI). CT and MRI offer the advantage of providing direct visualization of the structural abnormality of the carpal tunnel and median nerve, but both of these modalities are expensive and time-consuming. Recently, high-resolution ultrasonography has been reported to be effective in the study of the musculoskeletal system. The authors designed a case-control study to assess the diagnostic value of high-resolution ultrasonography. Forty-eight patients, for a total of 96 hands, whose diagnosis was confirmed by self-administered questionnaire and electrodiagnostic tests, underwent high-resolution ultrasonographic studies. The authors compared the sonographic findings with the electromyographic data and the patients' severity scores on the self-questionnaires. Proximal swelling of the median nerve at the entrance to the carpal tunnel was found to correlate with the nerve conduction data. Also, compression of the median nerve under the transverse carpal ligament was found to correlate with the subjective symptoms. Although ultrasonography is not an ideal method of diagnosis for carpal tunnel syndrome, it may be helpful for estimating the symptom severity and nerve conduction deficit.     

Standard open decompression in carpal tunnel syndrome compared with a modified open technique preserving the superficial skin nerves: a prospective randomized study

PURPOSE: A common surgical treatment for carpal tunnel syndrome is open carpal tunnel decompression. This involves skin incision followed by sharp dissection straight down through fat and palmar fascia to the transverse carpal ligament, which is then divided. The incidence of scar discomfort ranges from 19% to 61%, and its cause is not fully understood. We conducted a prospective randomized controlled trial to investigate whether preservation of superficial nerve branches crossing the incision site reduces the incidence and severity of postoperative scar pain after open carpal tunnel release. METHODS: Forty-two patients with bilateral idiopathic carpal tunnel syndrome (84 hands) were included in the study. The patients were randomized to determine which hand was to have carpal tunnel decompression using a technique that would try to preserve the superficial nerve branches. The other hand had open carpal tunnel decompression without any attempt to preserve the superficial nerve branches. An assessment of each hand in each patient was performed immediately before surgery and at 6 weeks, 3 months, and 6 months after surgery. This assessment was performed with a questionnaire based on the Patient Evaluation Measure. RESULTS: We found no evidence of a difference in scar pain between the 2 methods at 6 weeks, 3 months, and 6 months. There was a significant difference in the length of surgery between the 2 groups. CONCLUSIONS: Scar pain scores in this series of open carpal tunnel decompressions were similar, whether or not an attempt was made to identify and preserve superficial nerve branches crossing the wound.     

Intermediate and long-term outcomes following simple decompression of the ulnar nerve at the elbow

INTRODUCTION: There is currently little consensus regarding the appropriate surgical approach to treatment of cubital tunnel syndrome (CubTS), and few studies have reported long-term follow-up of patients who have received surgical treatment for ulnar nerve compression at the elbow. METHOD: Seventy-four patients with a total of 102 cases of CubTS treated with simple decompression of the ulnar nerve were examined 1.0-12.4 years postoperatively. Ulnar nerve conduction studies (slowest conducting 5 cm segment of ulnar nerve motor fibers measured at the elbow) were performed both pre- and postoperatively. The primary clinical outcome was percentage relief of symptoms, divided into "excellent" outcome group or less (> or = 90% improvement or < 90% improvement). RESULTS: Ulnar nerve conduction improved pre- to postoperatively, but clinical improvement was not related to changes in velocity. Women reported greater clinical improvement than men, and weight gain in men (but not women) predicted less improvement. Relief of cubital tunnel symptoms was greatest for those arms receiving carpal tunnel release surgery simultaneous or subsequent to cubital tunnel release. DISCUSSION: Simple decompression may offer excellent intermediate and long-term relief of symptoms associated with CubTS. Although improvement in ulnar motor nerve conduction velocity occurs following treatment of CubTS, it may not be a consistent marker of perceived symptom relief. Finally, these findings suggest that less complete relief of symptoms following ulnar nerve decompression may be related to unrecognized carpal tunnel syndrome or weight gain.     

The use of free fat grafts in recalcitrant carpal tunnel: a retrospective study

We present a retrospective study evaluating the proclaimed beneficial effect of the use of fat grafts in patients with recalcitrant carpal tunnel syndrome. Twenty-one re-decompression operations with fat grafting (group I) and 20 routine re-decompressions (group II) were assessed postoperatively with a questionnaire, physical examination, and nerve conduction studies. Both groups were improved by the operative intervention, but no significant differences were found between the two surgical techniques for postoperative severity of symptoms, threshold sensation, pain assessment, nerve conduction velocities, or patients' satisfaction with the postoperative result. Only the postoperative functional status score of the fat grafted patients revealed a trend to a significantly worse outcome. The fat grafted patients sustained more problems with a hypersensitive scar at the wrist level immediately after surgery, although on long-term review there was no significant difference in scar tenderness between the two groups. We concluded that implantation of free fat grafts has not proved to be of additional benefit in patients with recalcitrant carpal tunnel syndrome.