Results of internal neurolysis of the median nerve for severe carpal-tunnel syndrome

Thirty-six hands in thirty-two patients had internal neurolysis of the median nerve and carpal tunnel release for severe carpal-tunnel syndrome. Median-nerve function was evaluated in all hands using Weber two-point discrimination and electromyography. Thenar-muscle strength or bulk, or both, were recorded in thirty hands. Ten hands also had Semmes-Weinstein monofilament pressure-testing. The indication for neurolysis in these selected patients was the presence of any one of the following: an increase in two-point-discrimination values, thenar-muscle atrophy, or denervation potentials in the thenar muscles. Twenty-two (76 per cent) of the twenty-nine hands that had had diminished two-point discrimination preoperatively regained normal sensibility. Seven (70 per cent) of ten hands that had had thenar-muscle weakness (grade 3 or less) preoperatively regained grade-4 or 5 strength. Nine (50 per cent) of eighteen hands that had had thenar-muscle atrophy regained normal muscle bulk. Seventy-six per cent of the patients in this series recovered sensation and 70 per cent recovered muscle strength, and the procedure was well tolerated. Although no studies comparing the results of treatment of severe carpal-tunnel syndrome with and without internal neurolysis have been reported, we think that neurolysis, if it is done by a surgeon who is skilled in microsurgery, is a safe and effective procedure for severe carpal-tunnel syndrome.     

Results of endoscopic management of primary versus recurrent carpal tunnel syndrome in long-term haemodialysis patients.

In long-term haemodialysis patients, carpal tunnel syndrome (CTS) frequently occurs as a result of amyloid deposition, originating from beta-2 microglobulin, to the flexor retinaculum, paratenons and tendons themselves, which leads to an increase in carpal canal pressure and compression of the median nerve. Surgical procedures can rectify the condition, but continuing maintenance haemodialysis sometimes causes recurrence. We endoscopically operated 1848 hands primarily, 104 recurrent post-endoscopic procedure hands and 130 recurrent post-open procedure hands using the Universal Subcutaneous Endoscope (USE) system, then analysed clinical symptoms and electrophysiological recovery for more than six months post-operatively. The patients were satisfied with the clinical results. Optimal electrophysiological improvements were reported. There were no statistical differences between three groups, except in recovery of touch sensation, which was better in the post-endoscopic group than in the post-open group. There were no complications in this series. Our minimally invasive endoscopic procedure, using the USE system, is safe and effective for primary and recurrent CTS in haemodialysis patients.     

Patients surviving more than 10 years on haemodialysis. The natural history of the complications of treatment

Background: The purpose of this survey was to describe the natural history of complications in 52 long-surviving haemodialysis patients to obtain a clearer picture of the impact these patients have on the dialysis population. This is important as they are often no longer suitable for transplantation and therefore are destined to remain on dialysis for the rest of their lives. Methods: The patients who survived for more than 10 years on haemodialysis alone were studied. Information was obtained from patients' records and from the renal unit computer. Results: Mean age at start of dialysis was 43 years and mean duration of HD 14.5 years. Renal failure was most commonly due to polycystic kidney disease or glomerulonephritis. Sixty-two percent of patients developed cardiovascular disease, 78% complained of joint pains, 72% had a parathyroidectomy, and 50% developed carpal-tunnel syndrome. Two hundred and forty-five episodes of infection were recorded, 41% related to vascular access acquired in hospital or on immunosuppression. Only three infections occurred which could be described as opportunistic. Twelve patients were hepatitis C positive. In the 37 patients who have died, cardiovascular disease was the most common cause of death. Compared to other patients who started on dialysis before 1986 but who had a successful transplant the survival of patients on haemodialysis is much worse. Conclusion: Long-term survival on renal replacement therapy is dependent on successful transplantation. Complications, morbidity, and mortality are high after 10 years of dialysis.     

Endoscopic carpal tunnel release in patients receiving long-term hemodialysis

This study evaluated the clinical results of endoscopic carpal tunnel release in carpal tunnel syndrome caused by long-term hemodialysis and compared the results with that of idiopathic carpal tunnel syndrome. Operations were done in 32 patients (60 hands) with idiopathic carpal tunnel syndrome and in eight patients (15 hands) with carpal tunnel syndrome resulting from long-term hemodialysis. There was no significant difference in findings of preoperative evaluations and postoperative clinical results between the two groups, except for a difference with the patient satisfaction score with surgery on a visual analogue scale. The mean satisfaction score was 9.0 at 6 months, 9.3 at 1 year, and 9.5 at the 2-year followup in the group of patients with idiopathic carpal tunnel syndrome. However, in the group of patients with carpal tunnel syndrome resulting from long-term hemodialysis, the mean satisfaction score was 8.5 at 6 months, 8.2 at 1 year, and 6.5 at the 2-year followup. The score began to decrease at an average of 17.2 months after surgery. Long-term hemodialysis related carpal tunnel syndrome showed satisfactory short-term clinical results until approximately 1.5 years after the operation. After that time, the symptoms tended to deteriorate in 50% of the patients who received hemodialysis continuously.     

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.     

Carpal-tunnel syndrome. Results of a prospective trial of steroid injection and splinting

In order to define the role of steroid injection and splinting as a method of treatment of carpal-tunnel syndrome, a prospective study was performed on fifty hands in forty-one consecutive patients. All hands were treated with a single injection and three weeks of splinting. Follow-up ranged from a minimum of six months to a maximum of twenty-six months, with a mean of eighteen months. All hands had characteristic symptoms of median-nerve compression at the wrist and increased distal median motor latencies. Eleven (22 percent) of fifty hands were completely free of symptoms at the end of the follow-up period. Hands that initially had mild symptoms and findings of less than one year's duration, normal sensibility, normal thenar strength and mass, and one to two-millisecond prolongations of either distal median motor or sensory latencies had the most satisfactory responses to injections and splinting. Hands with severe symptoms of more than one year's duration and findings of atrophy, weakness, and distal motor latencies of more than six milliseconds or absent sensory responses had the poorest response to injections and experienced a high rate of relapse.     

Systemic lupus erythematosus: A follow-up study of Japanese patients with end-stage renal failure treated with haemodialysis

Summary: In order to explore the clinical course of Japanese patients with systemic lupus erythematosus (SLE) in end-stage renal failure, the clinical findings from 26 patients who had received haemodialysis were analysed. Each patient was followed for 72 months from the onset of clinical lupus nephritis to the initiation of haemodialysis. In most patients, renal disease progressed to end-stage renal failure despite clinical quiescence of SLE, which remained inactive throughout haemodialysis treatment. Seven patients (27%) had clinically active SLE with high dose prednisolone (mean; 49.3 mg per day) at initiation of haemodialysis. These patients had relatively rapid progression of their renal failure and 2 patients died within 1 month of their first haemodialysis. During the follow-up period from starting haemodialysis for an average of 44 months, most patients received ongoing haemodialysis while their SLE remained clinically inactive. Six patients (23%) died, 5 of those within 1 month from starting hemodialysis. the results of this long-term follow up of a large number of haemodialysis patients with lupus nephritis indicate that: (i) most patients with lupus nephritis undergoing haemodialysis have an excellent survival rate; and (ii) patients with active SLE at initiation of haemodialysis have a high mortality rate (within 1 month). We therefore conclude that more effective treatment for SLE in the presence of renal failure is required for these patients.     

Risk of death and liver cirrhosis in anti-HCV-positive long-term haemodialysis patients.

BACKGROUND: Hepatitis C virus (HCV) infection is the most common cause of chronic liver disease in haemodialysis patients. The aim of this study was to assess the impact of HCV infection on patient survival in a cohort of long-term haemodialysis patients and to evaluate the percentage of anti-HCV-positive patients that evolve to liver cirrhosis. METHODS: In 1992, 175 patients who had been on intermittent haemodialysis therapy for at least 6 months were included in the study (57 anti-HCV-positive and 118 anti-HCV-negative patients). Evaluation of patient outcome included date and cause of death, kidney transplantation, and the diagnosis of liver cirrhosis. Patient survival was estimated by the Kaplan-Meier method and compared by the log-rank test. The Cox proportional hazards model was used to estimate the risk of death among dialysis patients who were anti-HCV positive. Other prognostic variables studied included age, gender, diabetes mellitus as cause of end-stage renal disease (ESRD), history of previous transplant, transplantation during follow-up, and time on haemodialysis treatment. The diagnosis of liver cirrhosis was made based on clinical and/or histological criteria. RESULTS: Eight-year patient survival in anti-HCV-positive subjects was lower (32%) than in anti-HCV-negative patients (52%) (log-rank, P=0.03). Four variables were found to be independent prognostic factors in patient survival: age (relative risk (RR) 1.04); diabetes as cause of ESRD (RR 3.6); transplantation during follow-up (RR 0.66) and presence of HCV antibodies (RR 1.62). The causes of death did not differ significantly between groups, except that four anti-HCV-positive patients died from liver disease. Ten (17.5%) of the 57 anti-HCV-positive patients were diagnosed to have liver cirrhosis at a median of 10 years after renal replacement therapy initiation and a median of 7 years after the first ALT level increase. CONCLUSION: In conclusion, our study shows an increased risk of death among long-term haemodialysis patients infected with HCV compared with non-infected patients. This might be partly explained by the high proportion of these patients that evolve to liver cirrhosis.     

Idiopathic sudden sensorineural hearing loss in patients undergoing long-term haemodialysis

Idiopathic sudden sensorineural hearing loss (ISHL) has been recently recognized and is increasing in frequency in patients undergoing long-term haemodialysis. Although this is one of the annoying complications impairing quality of life in haemodialysis patients, there has been little clinical evidence about ISHL in haemodialysis patients until now. We have examined retrospectively the clinical features of 6 ISHL patients, 3 males and 3 females, with a mean age of 54 years, who underwent regular haemodialysis with a mean haemodialysis duration of 90 months from 1985 to 1989. Although a specific cause for ISHL could not be identified in this study, more precise clinical features of ISHL in patients undergoing haemodialysis have been elucidated. ISHL seemed to develop more frequently in haemodialysis patients and occurred in patients undergoing haemodialysis for a relatively long time, being independent of the high-frequency-deficit type hearing disturbances usually observed in the early course of haemodialysis therapy. Above all, diabetic haemodialysis patients were more susceptible to ISHL, occurring in 4 cases out of 6. Its prognosis was not necessarily bad, showing a recovery rate of 83%, but more effective therapy should be explored for improving the quality of life in haemodialysis patients.     

Palmar hyperhidrosis and its surgical treatment: a report of 100 cases.

One hundred patients with primary palmar hyperhidrosis (HH) underwent bilateral upper dorsal sympathectomy (UDS) by the supraclavicular approach. Pre-operative epidemiological and clinical data are described. The immediate and late results, as well as the complications and side-effects are detailed. Follow-up was completed on 93 patients between four and 50 months after the operation (average 18 months). Of 93 patients, 91 had drying of the hands. In 58% some moisture returned to the hands but in no case did the hyperhidrotic state recur. Subjective patient evaluation was excellent or good in 83 patients (89%) and only one patient (a technical failure) was completely dissatisfied. Reasons for some degree of dissatisfaction with operation were mainly compensatory HH in non denervated areas, and Horner's syndrome. Compensatory HH usually decreased with passage of time and, permanent Horner's syndrome occurred in 8% of patients (4% of procedures). Technical failure can be avoided by use of frozen section examination intraoperatively. For severe cases of palmar HH that cause social, professional and emotional embarassment, bilateral simultaneous UDS by the supraclavicular approach is the procedure of choice: Morbidity is small, and almost all patients enjoy improved quality of life after the operation.     

Case control study on dialysis arthropathy: the influence of two different dialysis membranes: data from the EDTA Registry

In a retrospective case control study the prevalence of signs and symptoms of dialysis osteoarthropathy was analysed. Cases and controls had received over 9 years of maintenance haemodialysis uninterrupted by peritoneal dialysis or transplantation. The cases comprised 55 patients treated predominantly with polyacrylonitrile (AN69) dialysers. They were compared to a matched group dialysed exclusively with cellulosic membranes. Over 60% of all patients, cases and controls, showed one or more signs of disabling osteoarthropathy, with joint pains occurring more frequently in the older age groups. Twenty-seven of the 55 cases who had received less than 2 years of cellulosic membrane dialysis followed by 7-12 years of AN69 dialysis tended to have a lower prevalence of joint pains, carpal-tunnel syndrome and bone cysts. However, no statistically significant differences were obtained compared to the matched control group dialysed exclusively on cellulosic membranes (mostly cuprophane). The remaining 28 cases, who had been treated for more than 2 years with cellulosic membranes preceding the longer treatment period with polyacrylonitrile dialysers, showed a prevalence similar to that of their cellulosic controls. This study thus shows little, if any, influence of the two types of membranes on the prevalence of signs and symptoms of beta 2-microglobulin amyloidosis.     

Glycaemic control and serum intact parathyroid hormone levels in diabetic patients on haemodialysis therapy.

BACKGROUND: Osteodystrophy is one of the long-term haemodialysis complications, and in diabetic patients, it mainly occurs as an aplastic or low-turnover type due to their low serum intact parathyroid hormone (iPTH) levels. In the present study, we investigated the role of glycaemic control to the serum iPTH levels in diabetic haemodialysis patients. METHODS: A total of 162 patients who had started haemodialysis at our hospital in the last 10 years were enrolled. Among them, 80 patients suffered from diabetic nephropathy as a primary cause of end-stage renal failure, 69 chronic glomerulonephritis, 9 polycystic kidney and 4 from other causes. We examined the serum iPTH and HbA(1c) levels of all patients at the start of haemodialysis. In 80 diabetic patients, we examined those levels both at the start of haemodialysis and 1 year later and investigated how glycaemic control affected the iPTH levels. RESULTS: The serum iPTH levels at the start of haemodialysis were significantly lower in patients with diabetes than without diabetes (P=0.032). The levels were lower in patients with poor glycaemic control than with good control (P=0.045). In the analysis of diabetic patients 1 year later, the serum iPTH levels were significantly reduced in those with poor glycaemic control (P=0.002). The multiple regression test showed that the serum HbA(1c) levels were strongly related to the serum iPTH levels (P<0.001). CONCLUSIONS: The status of glycaemic control in diabetic haemodialysis patients affects the serum iPTH levels. Good glycaemic control should be required to prevent osteodystrophy.     

Carpal tunnel syndrome in patients who are receiving long-term renal hemodialysis

In forty-six (9 per cent) of 485 patients who were receiving long-term renal hemodialysis, a carpal tunnel syndrome developed in at least one hand. A total of sixty-four surgical procedures were performed for this problem in forty-one patients. All of the forty-one patients reported symptomatic relief, although three had recurrent symptoms. There was no correlation between the time of onset of the carpal tunnel syndrome and such factors as the patient's age, sex, or race; the cause of renal failure; the site of vascular access for hemodialysis; or a history of parathyroidectomy. There was a correlation, however, between the development of the carpal tunnel syndrome, the side of the longest functional vascular access, and the presence of arterial calcifications. In all eleven patients in whom a radial steal syndrome developed, an ipsilateral carpal-tunnel syndrome also developed. It was concluded that factors other than those involving the site of vascular access must have important etiological roles.     

Functional study of hands among patients dialysed for more than 10 years

Sixty-six haemodialysed (HD) in centre patients (24 h/m²/week,acetate bath, cuprophane membrane), with a mean age of 59.2years, treated for 16.7 ± 4.5 years, underwent clinicalexamination of their hands to determine anatomical and functionalalterations. For each hand a functional score was calculatedfrom a medicolegal technique based on sensitivity and angulationamplitude (rating from 0 to 100). Dialysis-related arthropathy(DRA), including carpal-tunnel (CT) syndrome, was scored aswell as hand muscle amyotrophia. Trigger fingers, abnormal synovial hypertrophy, and one or morenon-functional tendons were found in 15, 26, and 33% of thepatients respectively. Thirteen percent had pseudoporphyria.Amyotrophy was moderate or severe in 39%. The global functionalscore (mean of the two unilateral functional scores) decreasedwith time spent on haemodialysis and was correlated with theDRA score. The unilateral functional score was linked to tendinouslesions, amyotrophy, and presence of pulses, but not to CT surgeryor presence of AV fistula. Hands with ulnar insult at the elbowshown by electromyography had significantly lower functionalscores. Repercussions of hand functional alteration may have an importantsocial and psychological impact in daily life. The responsibilityof amyloidosis is evidenced by tendinous lesions and nervousentrapment. Ulnar palsy is also important because of the vitalmotor role of that nerve in hand function.     

Carpal tunnel syndrome surgery: identification of a neurophysiological high-risk category

Surgical decompression of the median nerve is a standardized treatment for carpal tunnel syndrome. After surgery a clinical and neurophysiological improvement is observed also on severe cases. We report 4 cases of carpal tunnel syndrome (CTS) in the hands of 3 patients with prolonged median wrist-thenar distal motor latency (longer than 10 ms, normal values < 4.0 ms) and absence of digit-wrist sensory responses. In these patients surgery caused complete loss of median nerve function. Such a marked increase of median distal motor latency (DML) is rare (0.6% in 500 CTS hands consecutively examined in our laboratory) and suggests the presence of a chronic condition with severe disruption of the myelin. On the basis of these anecdotal observations, we suggest that patients with median DML of 10 ms or more be considered at high risk for CTS surgery failure. Received: 5 July 2000; Accepted: 6 October 2000     

Endoscopic treatment of encephaloceles of the lateral wall of the sphenoid sinus.

OBJECTIVE: The suitability of the endoscopic approach for the treatment of an encephalocele of the lateral wall of the sphenoid is discussed. This is a retrospective review of 4 cases diagnosed with temporosphenoidal encephalocele and having a history of CSF leak who were surgically treated using an endoscopic endonasal approach between January 2001 and June 2002 at the Department of Otolaryngology of Sant'Orsola-Malpighi University Hospital and the Department of Neurosurgery at Bellaria Hospital in Bologna. METHODS: Three patients were female between 48 and 73 years of age (mean: 61 years). All patients had suffered from a CSF leak for 5 months to 18 years. None of the patients had a past medical history of head trauma. A fourth patient had undergone a previous microscopic approach for a previously misdiagnosed CSF leak wrongly ascribed to an empty sella. Three patients underwent an ethmoid-pterygo-sphenoidal endoscopic approach (EPSEA), while the patient who had undergone previous microscopic surgery, was treated using a transnasal transsphenoidal endoscopic approach. RESULTS: The follow-up of the patients ranged from 10 to 26 months (mean: 18 months) and no case of a recurrent CSF leak was observed postoperatively. CONCLUSIONS: In our report, the endoscopic approach was a useful tool for the treatment of encephaloceles of the lateral wall of the sphenoid sinus. In skilled hands, this technique permits both the resection of the encephalocele and the subsequent reconstruction of the defect also with a low rate of morbidity.     

Dorsal (AO/ASIF) pi-plate osteosynthesis in the treatment of distal intraarticular radius fractures

The results and complications using the dorsal 2.4 mm 2.7 mm (AO/ASIF) pi-plate for the treatment of distal radius fractures were evaluated in a prospective study of 42 patients followed up clinically and radiologically and seven patients followed up with telephone call and radiological follow-up for an average time of 12.1 (range 4-32) months in a group of 50 patients with intraarticular distal radial fractures treated consecutively using this method. Twelve complications occurred in 10 patients including two extensor tendon ruptures, two transient cases of CRPS Type 1 (Reflex Sympathetic Dystrophy, Algodystrophy), two instances of screw loosening, three cases of posttraumatic carpal tunnel syndrome and three permanent sensory irritations on the dorsum of the hands. Using the AO score, there were 37 successful and 12 tolerable results, with no unsatisfactory outcomes. Using the NYOWR scale, there were 17 very good and 25 good results, with no satisfactory or poor outcomes. These results suggest that this osteosynthesis provides adequate fixation of comminuted distal intraarticular radius fractures with a reasonable incidence of complications.     

Depression in chronic haemodialysed patients

SUMMARY:   From April 2000 to April 2001, a total of 108 chronic stable haemodialysed patients (34 males aged 57.76 ± 12.68 years under haemodialysis treatment for 31.41 ± 24.71 months and 74 females aged 54.99 ± 12.87 years under haemodialysis for 41.47 ± 33.47 months) were studied for signs of clinical depression. Depression was measured by using 'The Taiwanese Depression Questionnaire (TDQ)'. After analysing various possible factors, we chose to study three dimensions: affective change, somatic complaint and cognitive disturbance. Thirty-six (33.4%) of the patients were found to have TDQ scores above 19; our cut-off value. Diabetic patients were also found to have higher depression scores and affective change scores than those without diabetes. The elderly suffered more from somatic complaints, and patients without jobs also tended to have higher depression scores. We compared the nutrition indexes and uraemic toxin removal indexes of those with higher depression scores (score ≥19) with those with normal scores (score <19), and we found no differences between the two groups. We found that an underlying disease and job status were the major differences found in the two groups. Therefore, our findings suggest that the depression found in our chronic haemodialysed patients was not a result of the physical conditions, but a result of psychosocial problems indicating a need for psychosocial support for these patients.     

Carpal tunnel syndrome. An evaluation of the provocative diagnostic tests

In order to evaluate the usefulness of provocative tests (wrist-flexion test, nerve-percussion test, and tourniquet test) in the diagnosis of carpal tunnel syndrome, the results of provocative testing were evaluated in a group of patients (sixty-seven hands) with electrodiagnostically proved carpal-tunnel syndrome and in a group of fifty control subjects. The sensitivity and specificity of each test were calculated. The wrist-flexion test was found to be the most sensitive while the nerve-percussion test, although least sensitive, was most specific. The tourniquet test was quite insensitive and not very specific, and should not be used as a routine screening test in the diagnosis of carpal tunnel syndrome.     

Congenital clasped thumb: a review of forty-three cases

Over a 10-year period, 43 patients (75 hands) with congenital clasped thumb were seen in our institution. Three groups were identified: group I, 14 patients (24 hands) without contracture; group II, 14 patients (21 hands) with contractures of the palmar side; and group III, 15 patients (30 hands) with arthrogryposis multiplex congenita. Forty-two hands were treated with splinting alone and 16 hands with surgery. The remaining 17 hands were followed conservatively without splinting or surgery. The mean follow-up was 32 months. The results were evaluated by active abduction of the carpometacarpal joint and extension of metacarpophalangeal joint. All patients in group I showed good response to splinting, and the cause of the deformity appeared to be the predominance of the flexor muscles. In groups II and III, 10 patients (16 hands) who had severe deformity or no response to splinting were treated by release of the palmar soft tissues, skin grafts, and reconstruction of the extensors. Satisfactory results were obtained in 12 of 16 hands.