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.     

腕管综合征与肘管综合征功能评定标准的现状与建议

腕管综合征与肘管综合征是周围神经卡压中最常见的疾病,近年来报道日渐增多.在这些临床报道中由于疗效评定的方法各异,很难对各种治疗方法做出客观、科学、全面的评定,能否制定结合国情的统一标准是本文的目的,供全国同道讨论.     

Validity and reliability of patient selected goals as an outcome measure in overactive bladder

Introduction and hypothesis

The purpose of this study is to assess the validity of patient goal achievement in overactive bladder (OAB).

Methods

Data were taken from a placebo-controlled randomised trial of transdermal oxybutynin and open label extension study. Face validity was assessed using qualitative analysis. Convergent validity was assessed by comparison with objective symptom improvement. Responsiveness was assessed at 4?s, using the standardised effect size. Reliability was assessed between 4 and 12?weeks of treatment.

Results

Ninety-six women were randomised. There were moderate correlations (0.50?C0.51) between goal achievement and symptom improvement for urinary urgency and urge incontinence. Mean goal achievement demonstrated good reliability (intraclass correlation?=?0.82) but low responsiveness (r?=?0.14) between transdermal oxybutynin and placebo-treated groups.

Conclusions

Although patient goals have good face validity and can be reliably measured, they have limited convergence with conventional measures of OAB severity and improvement and low responsiveness.     

Electromyographic evaluation after endoscopic carpal tunnel release in idiopathic carpal tunnel syndrome

The purpose of this study was to electromyographically evaluate results in patients with carpal tunnel syndrome (CTS) who underwent endoscopic carpal tunnel release (ECTR). The subjects were 26 patients with idiopathic CTS (37 hands) who were followed for at least 6 months after ECTR. To compare results informatively, hands were classified into four groups: those with normal distal motor latency (DML) and sensory conduction velocity (SCV) were classified as group A, those with normal DML and abnormal SCV as group B, those with an abnormal DML and normal SCV as group C, and those with abnormal DML and SCV as group D. All but one of the hands were classified as group D on the basis of preoperative electromyographic evaluation, while one was classified as group C. The mean preoperative obtainable DML and SCV values were 7.2 m and 27.3 m/s, respectively. Postoperatively, 12 hands were in group A, 8 hands in group B, 2 hands in group C, and 15 hands in group D. The mean DML and SCV values at final follow-up were 4.3 ms and 40.8 m/s, respectively. Of the 25 hands with muscle atrophy before surgery, 6 hands were in group A, 5 hands were in group B, 1 hand was in group C, and 13 hands were in group D at final follow-up. Thenar muscle atrophy and denervation potentials were present before surgery in 13 of the 15 hands classified as group D at the final follow-up. Received for publication on June 23, 1998; accepted on Oct. 30, 1998     

Histoplasmosis presenting as the carpal tunnel syndrome

An otherwise asymptomatic 53 year old woman presented with symptoms typical of median nerve compression in the carpal tunnel. At operation, the tendon sheath was obviously inflamed. The diagnosis of histoplasmosis was made on microscopic examination of the surgical specimen. Cultures of synovial tissue grew H. capsulatum. Review of the literature and of experience at Barnes Hospital indicates that the carpal tunnel syndrome is a very unusual primary manifestation of histoplasmosis. However, as histoplasmosis is a treatable cause of the carpal tunnel syndrome, this diagnosis should be considered in endemic areas.     

Pyridoxine as an adjunct in the treatment of carpal tunnel syndrome

Nineteen consecutive patients with carpal tunnel syndrome were treated with pyridoxine. Two thirds of the patients who specifically presented symptoms of median neuropathy eventually required surgical release. Although pyridoxine may have a place alongside other nonsurgical modalities in the treatment of carpal tunnel syndrome, surgical release continues to be indicated in many patients with carpal tunnel syndrome.     

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.     

Tuberculosis presenting as carpal tunnel syndrome

A 44-year-old man presented with typical symptoms, signs, and laboratory findings of carpal tunnel syndrome. Mycobacterium tuberculosis was cultured from the flexor tenosynovium excised at surgery. Tuberculosis should be considered in the differential diagnosis of carpal tunnel syndrome with unexplained chronic synovitis. The diagnosis may be missed unless a tissue specimen is analyzed specifically with acid-fast stain and culture. Therapy should include excision of involved synovium, early postoperative mobilization, and appropriate chemotherapy.     

Acute carpal tunnel syndrome resulting from haemorrhage into the carpal tunnel in a patient on Warfarin

A case of acute compression neuropathy of the median nerve associated with haemorrhage into the carpal tunnel is presented. The condition occurred spontaneously in a patient on Warfarin for previous deep venous thrombosis. The signs and symptoms were those of acute tenosynovitis originating in the common flexor synovial sheath at the wrist with associated paraesthesia in the distribution area of the median nerve in the hand. The patient was afebrile and blood tests were normal.     

Treatment of worker's compensation cases of carpal tunnel syndrome: an outcome study.

The primary goal of this retrospective study was to determine the most effective treatment protocol to return worker's compensation patients with carpal tunnel syndrome (CTS) to their original jobs. By examining a homogeneous subject pool and using specific, functional outcome measures determined by what is needed to reduce worker's compensation costs, a treatment protocol could be developed benefiting both the employer and employee. A total of 121 charts of worker's compensation patients with diagnoses of work-related CTS were reviewed. For inclusion in the study, patients could have no other upper extremity disorder, they must have completed treatment for the CTS, and the etiology of their CTS could not be traumatic. A total of 58 patients were included. Those who received conservative treatment followed by surgery (n = 27) were compared with those who were treated with surgery only (n = 31). A chi-square test showed a significant relationship between type of treatment and return to work (chi2(1)=4.065; p=0.044). Of the 31 patients who received only surgical treatment, 83.9% returned to original employment. Of the 27 patients who received both conservative and surgical treatment, 59.1% returned to their original employment. While this is a small sample size, the findings suggest that conservative treatment alone is not effective in returning worker's compensation patients with CTS to work.     

Electrophysiological responsiveness and quality of life (QuickDASH, CTSI) evaluation of surgically treated carpal tunnel syndrome

Background  We evaluated the correlation between Japanese versions of patient-oriented questionnaires and electrophysiological examinations in patients with carpal tunnel syndrome (CTS). Methods  A series of 45 patients who were diagnosed with carpal tunnel syndrome and subsequently underwent carpal tunnel release surgery were analyzed. There were 8 men and 37 women with an average age of 64.8 years. They completed the Japanese Society for Surgery of the Hand version of the Carpal Tunnel Syndrome Instrument (CTSI-JSSH), which consisted of a Symptom Severity Score (CTSI-JSSH-SS), Functional Score (CTSI-JSSH-FS), and Japanese Society for Surgery of the Hand version-Quick Disability of Arm, Shoulder, and Hand questionnaire (QuickDASH-JSSH) both preoperatively and 3 months postoperatively. Nerve conduction studies (NCSs) were also performed and included motor distal latency (MDL) and sensory nerve conduction velocity (SCV) measurements. The responsiveness of each instrument was evaluated by calculating the standardized response mean (SRM) and effect size (ES). Correlation coefficients between preoperative and postoperative questionnaire scores and NCS parameters were calculated. Results  Responsiveness (SRM/ES) was as follows: CTSI-JSSH-SS (-1.06/-1.14), CTSI-JSSH-FS (-0.75/-0.74), Quick-DASH-JSSH (-0.65/-0.62), MDL (-1.45/-1.11), and the neurophysiological stage of the disease (-0.90/-1.42). No significant correlation was observed between the preoperative and postoperative patient-oriented questionnaires and nerve conduction studies (P > 0.05). Conclusions  Although NCSs and the Japanese version of patient-oriented questionnaires are highly responsive to treatment, they are not parallel. Multifaceted assessment of CTS treatment is possible by performing both outcome measurements.     

Acute carpal tunnel syndrome in a patient taking coumadin

This is a case report of a 66-year-old female who had been taking coumadin for 4 weeks for deep vein thrombosis. She developed acute carpal tunnel syndrome following minor trauma to her wrist. After conservative therapy failed to relieve her symptoms she underwent release of her carpal tunnel with resolution of her symptoms. While there are many patients taking coumadin, its association with acute carpal tunnel syndrome is quite rare: we were only able to find only one other reported case in the literature. While one is tempted to treat these patients conservatively, operative therapy may be indicated.     

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.     

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.     

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.     

复发的腕管综合征的显微外科治疗

目的 探讨复发的腕管综合征(CTS)的显微外科治疗效果. 方法 2001年6月至2009年12月采用显微神经松解联合带血管蒂小鱼际皮下脂肪瓣(HTFPF)治疗21例复发的CTS患者,男5例,女16例;年龄35～78岁,平均52.2岁.17例采用腕管切开松解减压术后复发,4例采用内镜下腕管松解术后复发.术后复发时间5 ～35个月,平均19.6个月.按照CTS分型:中度8例,重度13例.所有患者桡侧3～4个手指麻木、疼痛,有麻刺感;Tinel征均阳性;食指指腹两点分辨觉5～14mm,平均9.3mm;握力6～18 kg,平均11.7 kg.所有患者复发后采取保守治疗3周均无效.结果 21例患者术后获18 ～48个月(平均24.4个月)随访.正中神经卡压症状明显改善时间2～14d,平均7.2d;两点辨别觉提高至2～8mm,平均4.0 mm;握力18～37 kg,平均23.5 kg.所有患者手指活动、感觉正常,麻木、针刺感消失,无明显的腕部疼痛,拇指对掌功能正常,肌电图检查均阴性,Tinel征、Phalen征、Reverse Phalen征均阴性.术后18个月,按CTS功能评定标准:优16例,良4例,可1例,优良率为95.2％,腕部主观疼痛减轻率达100％.所有患者均恢复正常工作和生活.全部患者术后未出现支柱疼痛、小鱼际疼痛、反射性交感神经营养不良、正中神经及其返支、掌浅弓损伤等并发症. 结论 显微外科治疗是治疗复发的CTS的有效方法,显微神经松解联合HTFPF可以恢复正中神经的滑动,并提供良好的软组织营养基床,显著改善复发的CTS患者的症状.     

Mycobacterium tuberculosis-induced carpal tunnel syndrome: management and follow-up evaluation

PURPOSE: To determine the clinical characteristics of 12 patients with Mycobacterium tuberculosis-induced carpal tunnel syndrome. This article also presents our intraoperative findings and surgical treatment results. METHODS: Twelve patients with tuberculosis-induced carpal tunnel syndrome who had surgery during a 10-year period that began in March 1991 were reviewed. The entrance criterion was a positive histologic report of tuberculosis for surgical specimens. The preoperative evaluation leading to diagnosis was reviewed for all patients. Transection of the transverse carpal ligament and complete synovectomy were performed for all patients. After surgery the patients were given an antituberculosis regimen for 1 year and were followed up for an average of 6 years. RESULTS: Twelve cases from a total of 1,180 patients with carpal tunnel syndrome were traced to M tuberculosis involvement of synovial tissue of the flexor tendons. Ten patients had large rice bodies in thick synovial membranes, and in the other 2 patients thick synovial tissue with yellow exudates were observed during surgery. In contrast to tendon involvement with rupture, no direct median nerve involvement was noted. Histopathologic study results of surgical specimens were positive for tuberculosis in all patients. Eight of 10 initial smears showed acid-fast bacillus and all 10 cultures of the specimens were positive for tubercle bacilli. Surgery and antituberculosis therapy were associated with a desirable outcome and sensory disturbance in the median nerve distribution resolved in all patients. Anterior wrist swelling disappeared and there has been no clinical or laboratory evidence of recurrence in all treated patients. CONCLUSIONS: Early diagnosis and surgical treatment combined with antituberculosis medical treatment are important in treating this condition. All patients treated were relieved of symptoms of synovial proliferation at the wrist, with no recurrence of the condition during the follow-up period. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.