Surgical outcome of endoscopic carpal tunnel release in 100 patients with carpal tunnel syndrome.

The purpose of this study is to present the surgical outcome of endoscopic carpal tunnel release (ECTR) for the treatment of carpal tunnel syndrome (CTS). One hundred and thirty-one procedures (36 right hands, 33 left hands and 31 bilateral hands) of single portal ECTR were performed upon 100 patients (age range: 36-77 years, mean age: 52.9 years; 98 women and 2 men) with electrodiagnostically proven CTS for 2.5 years from 2001. Preoperative clinical severity and results of electrodiagnostic studies were compared with surgical outcomes at the minimal 3-month postoperative period. Among 131 cases 125 (95.4 %) with complete or significant relief of symptoms were satisfied and 6 (4.6 %) with partial or no relief of symptoms were dissatisfied. There were 2 cases of major complications (one with ulnar nerve injury and the other with ulnar artery injury) that developed in our early experience of ECTR and 1 case of recurrence. The grade of electrodiagnostic abnormalities was associated with surgical outcome but there was no statistical significance between them. The severity of clinical findings, age at onset and symptom duration were not correlated with surgical outcome. In conclusion, ECTR surgery was effective in relieving the symptoms of CTS with a low complication rate after the learning curve period. Thus, ECTR can be an alternative to the traditional open surgery and can be the first procedure for CTS with several advantages over open methods.     

Critical analysis of outcome measures used in the assessment of carpal tunnel syndrome

Clinicians and researchers are confounded by the various outcome measures used for the assessment of carpal tunnel syndrome (CTS). In this study, we critically analysed the conceptual framework, validity, reliability, responsiveness and appropriateness of some of the commonly used CTS outcome measures. Initially, we conducted an extensive literature search to identify all of the outcome measures used in the assessment of CTS patients, which revealed six different carpal tunnel outcome measures [Boston Carpal Tunnel Questionnaire (BCTQ), Michigan Hand Outcome Questionnaire (MHQ), Disability of Arm, Shoulder and Hand (DASH), Patient Evaluation Measure (PEM), clinical rating scale (Historical-Objective (Hi-Ob) scale) and Upper Extremity Functional Scale (UEFS)]. We analysed the construction framework, development process, validation process, reliability, internal consistency (IC), responsiveness and limitations of each of these outcome measures. Our analysis reveals that BCTQ, MHQ and PEM have comprehensive frameworks, good validity, reliability and responsiveness both in the hands of the developers, as well as independent researchers. The UEFS and Hi-Ob scale need validation and reliability testing by independent researchers. Region-specific measures like DASH have good frameworks and, hence, a potential role in the assessment of CTS but they require more validation in exclusive carpal tunnel patients.     

Stress carpal tunnel pressures in patients with carpal tunnel syndrome and normal patients

Twenty-two patients with carpal tunnel syndrome scheduled to have a carpal tunnel release, and six volunteer control subjects had carpal tunnel pressures measured with their wrist in neutral position, maximum flexion, and maximum extension. The wrist was then repetitively flexed and extended to maximum position at a rate of 30 full cycles per minute for 1 minute. Pressures were then continually monitored and recorded at 30-second intervals. The pressures were found to be significantly elevated in the immediate post-exercise period in the patients with carpal tunnel syndrome, and they demonstrated a prolonged recovery time to reach the resting pressure when compared with the normal control subjects. This property of prolonged recovery time in patients with carpal tunnel syndrome suggests a possible cause for carpal tunnel syndrome in the occupational setting.     

Protocol of outcome evaluation for surgical release of carpal tunnel syndrome

OBJECTIVE: To propose and apply a protocol for assessing the outcome of surgery for carpal tunnel syndrome. METHODS: The protocol included a patient questionnaire that was self-administered before and 1 and 6 months after the operation to assess severity of symptoms (Boston questionnaire) and staging according to clinical (Giannini) and electrophysiological (Padua) severity scales. RESULTS: The results of a prospective series of 323 hands undergoing surgery for carpal tunnel syndrome by the mini-incision of the palm technique are reported. CONCLUSION: The method was found to be valid, precise, reliable, and straightforward, enabling a comparison of the results from different patient series and different operating techniques.     

Segmental carpal canal pressure in patients with carpal tunnel syndrome

PURPOSE: To clarify which part of the median nerve is the most compressed and to compare carpal canal pressure with the latency of the sensory nerve potential and the duration of symptoms. METHODS: Fifteen patients with idiopathic carpal tunnel syndrome were studied using a pressure guidewire system to record canal pressure. The wire was introduced from the distal end of the carpal canal to 2 cm proximal to the distal wrist crease (DWC) and then retracted in 5-mm increments using an image intensifier to guide the progress. A nerve conduction study was performed, and all patients were asked how long the symptoms lasted. RESULTS: Carpal canal pressure was significantly higher 5 to 15 mm distal to the DWC. The most compressed point was 10 mm distal to the DWC, with a pressure of 44.9 +/- 26.4 mm Hg. The correlation coefficient between the highest canal pressure and the latency was 0.393 and between highest canal pressure and duration of symptoms was 0.402. CONCLUSIONS: Our study showed that the most compressed part of the median nerve in the carpal canal is 10 mm distal to the DWC. The carpal canal pressure was related to the latency and to the duration of symptoms.     

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.     

Surgical efficacy of carpal tunnel release for carpal tunnel syndrome in acromegaly: report of four patients

Although carpal tunnel syndrome is frequent in acromegaly, few acromegalics will be encountered by most hand surgeons. This paper considers the treatment of four cases of acromegaly in whom carpal tunnel syndrome arose, to discuss aspects of management of carpal tunnel syndrome in this patient group.     

The relationship of the double crush to carpal tunnel syndrome (an analysis of 1,000 cases of carpal tunnel syndrome)

In this series of 1,000 cases of carpal tunnel syndrome (888 patients) there is a statistically significant incidence of bilaterality in patients with cervical arthritis. There is also a statistically significant increase in the incidence of diabetes mellitus over the general population. These findings lend further support to Upton's Double Crush hypothesis. Further, the double crush syndrome predisposes to bilateral carpal tunnel syndrome and may be an important prognostic factor. It may also be an explanation for some of the failures following carpal tunnel surgery and lead surgeons to look for other associated systemic diseases or mechanical blocks, when attempting to alleviate recalcitrant symptoms.     

The outcome of the nonoperated contralateral hand in carpal tunnel syndrome.

It is not well known how the nonoperated contralateral hand behaves in bilateral carpal tunnel syndrome (CTS). The postoperative clinical course of the nonoperated contralateral hand in unilateral CTS is not well documented either. Of 324 CTS patients, the authors studied 37 who had carpal tunnel release on one hand only to evaluate the postoperative outcome of the nonoperated contralateral hand. The other 287 patients had operations on both hands. Seven patients were excluded because of missing data or because they could not be contacted. All 324 patients were subject to clinical and electrodiagnostic studies on both hands. The patients were divided into three groups. Group I was composed of patients who had bilateral CTS, diagnosed clinically and electrophysiologically, but who had surgery done only on the hand with the most pronounced symptoms. The patients in group II showed symptoms of CTS in one hand only. However, the opposite hand was diagnosed with subclinical CTS: Electrodiagnostic studies showed involvement of the median nerve, but without symptoms. Group III was composed of true unilateral CTS patients, diagnosed by symptoms and electrodiagnostic study. The results of the electrodiagnosis were categorized according to the severity of median nerve damage (mild, moderate, severe). The outcome and postoperative clinical course of the nonoperated contralateral hand were evaluated by electromyography and telephone survey. This method of survey was used because of the vast spread of patients throughout the country. Within 1 year, all 30 operated hands showed significant improvement, 20 of which belonged to group I. Regarding progress of the nonoperated contralateral hand, 10 patients showed improvement of one grade whereas 5 patients showed three grades of improvement. In another 5 patients there was no change whatsoever. In addition, from groups II and III there were 5 patients who showed no change in the nonoperated hand. The postoperative electromyographic findings of the nonoperated contralateral hand was not commensurate with the symptoms. However, regardless of electromyographic results, the nonoperated contralateral hand showed significant improvement (p < 0.0001). Patients with unilateral CTS did not experience any symptom development in the nonoperated contralateral hand.     

Sensibility testing in patients with carpal tunnel syndrome

We evaluated the sensibility of the hand preoperatively and at intervals postoperatively in twenty-three hands of twenty patients with idiopathic carpal-tunnel syndrome who underwent carpal tunnel release. Tests of sensibility included the threshold tests (vibrometry, 256-cycles-per-second vibration, and Semmes-Weinstein monofilaments) and one innervation-density test (two-point discrimination). In addition the wrist-flexion test, nerve-percussion test, and tourniquet test were performed preoperatively. Only five of the twenty-three hands had abnormal two-point discrimination and each of these also had markedly abnormal threshold-test values. Nineteen of twenty-three hands preoperatively had decreased sensibility detected by both Semmes-Weinstein monofilament testing and vibrometry. Six weeks after carpal tunnel release, all of the hands demonstrated improvement on threshold testing, and 65 per cent had normal values.     

Effects of multiple injections of hypertonic dextrose in the rabbit carpal tunnel: a potential model of carpal tunnel syndrome development

Background

This study investigated the effects of a series of four hypertonic dextrose injections on the subsynovial connective tissue (SSCT) and median nerve within the carpal tunnel of a rabbit model.

Methods

Twenty New Zealand white rabbits were used. One forepaw carpal tunnel was randomly injected with 0.1 ml of 10 % dextrose solution. The contralateral forepaw was injected with a similar amount of saline. This injection was made once per week for 4 weeks. The animals were killed at 16 weeks after the initial injection and were evaluated by electrophysiology (EP), SSCT mechanical testing, and histology.

Results

Mechanical testing revealed significantly greater ultimate load and energy absorption in the dextrose injection group compared to the saline injection group (P?<?0.05). Histological evaluation revealed SSCT fibrosis and thickening and edema in the median nerve bundles in the dextrose injection group. There was a prolongation in the latency of the EP test in the dextrose injection group (P?=?0.08).

Conclusions

Previous studies had shown that one or two injections of 10 % dextrose could induce moderate SSCT fibrosis and mild EP changes without nerve histology changes. In this study, we have shown that higher doses create more severe fibrosis and, most importantly, more severe neuropathy, suggesting a dose–response effect, and confirming this as a potentially useful animal model for researching the etiology and treatment of carpal tunnel syndrome.     

Amyloidosis as a cause of carpal tunnel syndrome in haemodialysis patients

Over a five-year period (1981–1985), nine patients on haemodialysis developed carpal tunnel syndrome. Five patients, following biopsy of synovium in the carpal tunnel or biopsy of thickened epineurium of the median nerve, were found to have amyloid deposits in the soft tissues. The relationship between this condition, dialysis arthropathy and long-term haemodialysis is reviewed. In addition, in this small group of patients no relationship to the side of the fistula has been demonstrated and two patients developed recurrent problems despite initial open decompression of the carpal tunnel.     

Subjective and functional outcome after revision surgery in carpal tunnel syndrome

INTRODUCTION: In spite of carpal tunnel release's prevalent good postoperative results, the number of revision surgeries needed should not be underestimated. In this study, subjective and functional results after carpal tunnel revision surgery were determined. MATERIALS AND METHODS: Thirty-eight patients were examined approximately 2 years after their revision surgery of the carpal tunnel release. The subjective outcome of the patients was assessed using two different questionnaires (Amadio and DASH). A clinical examination was undertaken on selected patients who had persistent complaints. The clinical assessment analyzed grip strength, thumb opposition, pulp-to-pulp-pinch, key-pinch, hook-grip, Moberg-Pickup-test, two-point-discrimination, Phalen-test, and the Hoffmann-Tinel-sign. RESULTS: The subjective assessment showed that after the revision surgery, patients experienced load induced pain that occurred during daytime. However, the revision was able to improve the impaired sensibility. The functional outcome showed a persistent lack of strength when performing daily activities. The clinical assessment of the patients with relevant complaints confirmed the subjective outcome. CONCLUSION: The revision surgery can improve the impaired sensibility, particularly, paresthesia nocturna. The persistent weakness of the hand can only partly be improved. In spite of remaining complaints, revision surgery can yield satisfactory results for the patients.     

腕管综合征96例分析

自1993年1月-2000年12月,诊治腕管综合征96例,其中手术治疗31例,现将有关资料进行分析。1临床资料1.1一般资料本组96例,男25例,女71例;年龄为26～63岁,平均43岁。16例为双侧性,病程最短为1周,最长为10年。病因:腕部外伤史17例,手部关节酸痛史23例,18例女性患者认为发病与妊娠或     

Pressures in the carpal tunnel. A comparison between patients with carpal tunnel syndrome and normal subjects

We studied pressure in the carpal tunnel in patients with carpal tunnel syndrome and in normal control subjects, using a slit catheter and recording in the neutral position, 90 degrees dorsiflexion, and 90 degrees palmarflexion of the wrist. For each position the mean pressure in the patients was very significantly higher than in the controls, the highest pressure being in 90 degrees dorsiflexion, and the lowest in the neutral position. Using an upper limit of normal pressure of 5.5 mmHg in the neutral position gave a diagnostic sensitivity of 78.7%, a specificity of 78.1%, an accuracy of 78.5%, and a positive predictive value of 87.3%.     

Predicting the outcome of carpal tunnel release

PURPOSE: To test the hypothesis that the result of steroid injection in the carpal tunnel provides a better predictor of the outcome of later surgery. We also explored other possible factors that might predict the outcome directly or interact with the results of steroid injection to better predict the outcome. METHOD: We performed a historical cohort study on 57 patients who had carpal tunnel release. Care was taken to avoid problems of statistical nonindependence caused by both hands being studied and confounding from previous surgeries. RESULTS: We found a large and significant difference in the success rate of surgery for patients who had obtained some relief from injection (87%) versus those who had not (54%). No other significant predictor was found. We discovered factors that may interact with the results of injection in predicting the outcome of surgery (eg, Katz and Stirrat hand diagram assessment of the probability of carpal tunnel syndrome) although not significant in our study. CONCLUSIONS: Some relief from steroid injection is the best predictor for success of surgery. Further study is warranted to identify factors that interact with this predictor.