Carpal tunnel syndrome despite negative neurophysiological studies

The purpose of the present study was to compare the results of conservative and operative treatment for patients with carpal tunnel syndrome having normal neurophysiological studies. We studied 125 patients with normal neurophysiological studies and analysed eight symptoms and signs as "prognostic factors". Ninety-six patients were treated conservatively (splintage, steroid injection, antiinflammatory medications, activity modification) and 29 were treated surgically (open decompression). One year after initiation of treatment we assessed the outcome and statistically analysed (chi-square test) the differences between the two groups. We did not find any statistically significant correlation between "prognostic factors" and outcome. Twenty four percent of the group treated non-operatively had a good or excellent outcome, whereas 90% of the group treated operatively had a good or excellent outcome. This difference was statistically significant (p < 0.0001). Our study supports the view that the diagnosis of carpal tunnel syndrome is clinical and not neurophysiological. We now recommend operative treatment for these patients.     

Outcome of carpal tunnel decompression with pre-surgical diagnosis determined on general practitioner assessment and nerve conduction study

BackgroundAccurate diagnosis of carpal tunnel syndrome is key to successful treatment. At our center a treatment pathway was recently established for patients with carpal tunnel syndrome. Within this pathway patients are assessed by their community practitioner. Patients who fail to improve with conservative treatment and have a positive nerve conduction study are put forward for surgery without a specialist assessment. Recent literature has shown nerve conduction study may produce a high rate of false-positive results when used to diagnose carpal tunnel syndrome. The aim of this study was to retrospectively review outcomes of carpal tunnel decompression surgery in patients whose diagnoses was based on a community practitioner assessment and positive nerve conduction study.MethodsAll patients who had carpal tunnel release surgery between August 1, 2017 and August 31, 2018 at our center were screened for eligibility. Data from hospital records and a standardized telephone questionnaire was used to assess surgical outcome.ResultsThe final study population included 128 operated hands. The mean follow up time after surgery was 9.6 months. We found 79% of patients reported significant improvement of their symptoms following carpal tunnel release. The overall complication rate was 2.3%.ConclusionThis study has demonstrated good outcomes from carpal tunnel decompressive surgery are possible in a cohort of patients whose diagnosis was made on the basis of a positive nerve conduction study and community practitioner assessment.     

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.     

Long-term analysis of patients having surgical treatment for carpal tunnel syndrome

This retrospective study of 100 patients who had surgical treatment for their carpal tunnel syndrome was performed to determine what factors were associated with long-term success or failure. One hundred thirty hands were treated surgically with an average follow-up of 4 years (range, 2 to 6 years). All patients were given a course of conservative treatment that included steroid injection(s) and splinting until the patients were refractory to such therapy. Over 250 injections were given (117 wrists), with the average benefit time of 27 weeks (range 0 to 330). Most patients received two to three injections (maximum of nine). Variables associated with a failure to have long-term benefit after operation included weakness or atrophy of the abductor pollicis brevis muscle, presence of a predisposing condition, and failure to benefit from the initial steroid injection. Conversely, all 51 hands that had relief from median nerve paresthesia for more than 6 months by conservative therapy alone received long-term relief after surgery. Steroids were least effective in hands that had muscle involvement. Fifteen of the 40 hands with muscle involvement regained their muscle mass by the time of the final examination.     

Prospective comparison of the six-item carpal tunnel symptoms scale and portable nerve conduction testing in measuring the outcomes of treatment of carpal tunnel syndrome with steroid injection

Background

We prospectively studied patients clinically diagnosed with carpal tunnel syndrome (CTS) and treated with the injection of corticosteroid into their carpal tunnel in order to compare changes in the six-item CTS symptoms scale and portable nerve conduction study (NCS) parameters as outcome tools. Our pilot study was the first to assess the utility of the six-item CTS symptom scale (CTS-6) with steroid injections as a patient-directed outcome measure for the treatment of CTS.

Methods

We enrolled patients who presented to our county hospital orthopedic surgery clinic from August 2012 through August 2013. The patients were clinically diagnosed with CTS. After completing the six-item CTS symptoms scale questionnaire, portable NCS was obtained. Each patient then received an injection of 1 ml of triamcinolone acetonide 40 mg/ml mixed with 1 ml of 1 % lidocaine into the carpal tunnel. Six weeks postinjection, each patient repeated a CTS-6 questionnaire and underwent a repeat portable NCS. The CTS-6 and NCS results were analyzed using the paired samples t test. A Pearson correlation was used to assess the correlation between the changes in the CTS-6 and the NCS measurements. Statistical significance was set at P < 0.05.

Results

Thirty-two wrists in 20 patients were evaluated. There was a statistically significant difference between the CTS-6 scores before and after injection. There were also statistically significant changes in the five of the NCS parameters. None of the correlations between the CTS-6 and the NCS parameters were statistically significant.

Conclusions

The six-item CTS symptoms scale and portable NCS are both useful measures for evaluating the results of steroid injections. The CTS-6 is an effective tool because of its ease of use, low cost, correspondence with changes in NCS, and ability to monitor the outcome of steroid treatment for carpal tunnel syndrome.     

Prognostic ability of a good outcome to carpal tunnel release for decompression surgery in the lower extremity

For years, patients who were treated successfully with carpal tunnel release were told there was nothing that could be done about their lower extremity symptoms. Now that lower extremity nerve decompression has been accepted as an option to treat appropriate patients, the authors looked for correlations between a successful outcome with carpal tunnel syndrome and its predictive value of success for lower extremity nerve decompression. Data from a recent study demonstrate that a good result from upper extremity peripheral nerve surgery predicts the outcome for lower extremity peripheral nerve surgery in 88% of patients, and is, therefore, information valuable for prognosis and clinical decision-making.     

Clinical course of the non-operated hand in patients with bilateral idiopathic carpal tunnel syndrome

PURPOSE: Patients with bilateral carpal tunnel syndrome (CTS) who had unilateral carpal tunnel surgery usually ask about the prognosis for the non-operated, opposite hand. In this study, we investigated the effects of unilateral carpal tunnel surgery on the clinical course of the non-operated, opposite hand in bilateral idiopathic CTS. METHODS: In this prospective study, only patients who had bilateral idiopathic CTS but had unilateral carpal tunnel surgery were included. Sixty-six patients were included in the study. All patients were women with the mean age 47 years and mean duration of symptoms 4 years. Forty-six surgeries were performed on right hands, and 20 surgeries performed on left hands. Forty-eight (73%) patients were housewives. Their non-operated, opposite hands were evaluated before and 6 months after unilateral surgery. The evaluations consisted of subjective symptoms and objective findings. Paired t-test and chi-square test were used for statistical analysis. RESULTS: There were no statistically significant differences between the means of symptom severity score, functional status score, power and pinch grip strength before and 6 months after unilateral surgery in the non-operated, opposite hands. There was no statistically significant differences among the percentages of the Tinel's sign, Phalen test, and electrophysiological changes before and 6 months after unilateral surgery on the non-operated, opposite hands. During the study period, 57 (86%) patients had surgery or intended to have surgery for their opposite hands. CONCLUSIONS: It seems that unilateral surgery for bilateral idiopathic CTS does not affect the clinical course of the non-operated, opposite hand. We recommend that each hand of patients with bilateral CTS be managed separately, based on their symptoms.     

The minimal clinically important difference of the Carpal Tunnel Syndrome Symptom Severity Scale

PURPOSE: To identify the change score in the Symptom Severity Scale (SSS) of the Carpal Tunnel Syndrome (CTS) Questionnaire that is associated with an important change in clinical status. METHODS: Twenty-eight patients with CTS treated with a carpal tunnel steroid injection completed the Brigham and Women's Hospital CTS Questionnaire before steroid injections and at the 3-week follow-up visit. Satisfaction was determined by postcare review of the clinical management. To calculate the minimal clinically important difference, receiver operating characteristic curves were created. The area under the curve was calculated to determine and compare the responsiveness of the entire SSS and the pain and sensory questions in isolation. RESULTS: The SSS of the CTS Questionnaire, including its pain and sensory domain, can show a meaningful clinical improvement after carpal tunnel injection. The SSS, its sensory domain, and its pain domain were statistically better than chance. All 3 measures showed predictive ability; however, the total SSS was the most sensitive in detecting a change. The minimal clinically important difference in the score of the SSS after carpal tunnel steroid injection was found to be 1.04. CONCLUSIONS: The SSS can be used to distinguish a clinically important change after carpal tunnel injection. A decrease of 1.04 or more in the SSS score may indicate a clinically important change in a patient's state of health. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level I.     

Single-portal endoscopic carpal tunnel release compared with open release : a prospective,randomized trial

BACKGROUND: Carpal tunnel syndrome is a common condition causing hand pain and numbness. Endoscopic carpal tunnel release has been demonstrated to reduce recovery time, although previous studies have raised concerns about an increased rate of complications. The purpose of this prospective, randomized study was to compare open carpal tunnel release with single-portal endoscopic carpal tunnel release. METHODS: A prospective, randomized, multicenter center study was performed on 192 hands in 147 patients. The open method was performed in ninety-five hands in seventy-two patients, and the endoscopic method was performed in ninety-seven hands in seventy-five patients. All of the patients had clinical signs or symptoms and electrodiagnostic findings consistent with carpal tunnel syndrome and had not responded to, or had refused, nonoperative management. Follow-up evaluations with use of validated outcome instruments and quantitative measurements of grip strength, pinch strength, and hand dexterity were performed at two, four, eight, twelve, twenty-six, and fifty-two weeks after the surgery. Complications were identified. The cost of the procedures and the time until return to work were recorded and compared between the groups. RESULTS: During the first three months after surgery, the patients treated with the endoscopic method had better Carpal Tunnel Syndrome Symptom Severity Scores, better Carpal Tunnel Syndrome Functional Status Scores, and better subjective satisfaction scores. During the first three months after surgery, they also had significantly (p < 0.05) greater grip strength, pinch strength, and hand dexterity. The open technique resulted in greater scar tenderness during the first three months after surgery as well as a longer time until the patients could return to work (median, thirty-eight days compared with eighteen days after the endoscopic release). No technical problems with respect to nerve, tendon, or artery injuries were noted in either group. There was no significant difference in the rate of complications or the cost of surgery between the two groups. CONCLUSION: Good clinical outcomes and patient satisfaction are achieved more quickly when the endoscopic method of carpal tunnel release is used. Single-portal endoscopic surgery is a safe and effective method of treating carpal tunnel syndrome.     

Comparison of carpal tunnel injection techniques: A cadaver study

The purpose of the study was to evaluate the accuracy of injections into the carpal tunnel using three different portals in cadavers, and to define safe guidelines. In this study, 150 wrists of 75 cadavers (54 male, 21 female) were included. To compare three injection sites, 50 wrists of 25 cadavers were used for each technique; we used 23 gauge needles, and acrylic dye. The first injection technique: the needle was inserted 1cm proximal to the wrist crease and directed distally by roughly 45 in an ulnar direction through the flexor carpi radialis tendon. The second injection technique: the needle was inserted into the carpal tunnel from a point just ulnar to the palmaris longus tendon and 1cm proximal to the wrist crease. The third injection technique: the needle was inserted just distal to the distal skin crease of the wrist in line with the fourth ray. The first injection technique gave the highest accuracy rate, and this was also the safest injection site. Median nerve injuries caused by injection was seen mostly with the second technique. Although a steroid injection may provide symptomatic relief in patients with carpal tunnel syndrome, the median nerve and other structures in the carpal tunnel are at risk of injury. Because of that, the injection should be given using the correct technique by physicians skilled in carpal tunnel 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.     

Common risk factors seen in secondary carpal tunnel surgery

BACKGROUND: We hypothesized that there are several common risk factors associated with secondary carpal tunnel releases. Therefore, we chose to investigate these common factors by analyzing the charts of those patients requiring a second carpal tunnel release (CTR) procedure. METHODS: A retrospective chart review was performed, and patients were identified by searching hospital medical record databases using the Common Procedural Terminology. RESULTS: Between January 1, 2000, and March 31, 2004, 2357 patients had a primary CTR, and 48 of them were found to have had a secondary CTR (of these 48, 9 had diabetes mellitus, 11 had hypertension, and 6 had gastrointestinal-related illnesses). Seven percent of those who had an open release primarily required a second CTR, while only 0.2% of those who had an endoscopic release primarily required a second CTR. CONCLUSION: A greater number of secondary CTR procedures were required for those patients with symptoms of carpal tunnel syndrome in the group that had an open release primarily versus those that had an endoscopic release primarily. Diabetes mellitus and hypertension may also contribute to the need for secondary surgery.     

Can the outcome of carpal tunnel release be predicted?

Between 1994 and 1996 we performed a prospective study on the effect of carpal tunnel release on the health status of 96 patients. The Nottingham Health Profile, a validated global scoring system, was used to assess quality of life before, and at 4 months after surgery. Carpal tunnel syndrome had a significant impact on the health status of our patients. There were significant improvements in the scores for pain, energy and sleep. Patients who were dissatisfied following surgery had significantly higher pre-operative scores, indicating poor perceived health status. Our findings show that outcome assessment tools have predictive value in identifying patients who may not benefit from surgery, or in whom a poor result might be anticipated.     

The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome

In a prospective study, we have evaluated the impact of psychological disturbance on symptoms, self-reported disability and the surgical outcome in a series of 110 patients with carpal tunnel syndrome. Self-reported severity of symptoms and disability were assessed using the patient evaluation measure and the Boston carpal tunnel questionnaire. Psychological distress was assessed using the hospital anxiety and depression scale. There was a significant association between psychological disturbance and the pre-operative symptoms and disability. However, there was no significant association between pre-operative psychological disturbance and the outcome of surgery at six months. We concluded that patients with carpal tunnel syndrome should not be denied surgery because of pre-operative psychological disturbance since it does not adversely affect the surgical outcome.     

Patient satisfaction after open carpal tunnel release correlates with depression

PURPOSE: To test the null hypothesis that depression does not correlate with patient satisfaction after open release of electrodiagnostically confirmed carpal tunnel syndrome when controlling for other demographic, disease-related, and psychosocial factors. METHODS: Eighty-two survey respondents who had recovered (minimum 2 years after surgery) from a limited incision open carpal tunnel release completed measures of satisfaction, perceived disability, depression, pain catastrophizing, and pain anxiety. Univariate and multivariate analyses sought predictors of satisfaction and perceived disability from among demographic, disease related, and psychological factors. RESULTS: The average satisfaction score was 8 points (range, 0-10) and the average Disabilities of the Arm, Shoulder, and Hand score was 13 points (range, 0-76). Predictors of greater dissatisfaction included greater depression and the categorical electrophysiologic test rating. Predictors of perceived disability included depression, pain catastrophizing, and static numbness. Depression was the dominant predictor of both satisfaction and perceived disability. CONCLUSIONS: Dissatisfaction and perceived disability after limited open carpal tunnel release for electrodiagnostically confirmed idiopathic carpal tunnel syndrome is predicted primarily by depression and ineffective coping skills and to a lesser degree by clinical or electrophysiologic evidence of advanced nerve damage. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.     

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.     

Comparing the outcome of a carpal tunnel decompression at 2 weeks and 6 months

PURPOSE: The purpose of the study was to evaluate if 2-week Levine score can provide an adequately responsive outcome measure in carpal tunnel decompression by comparing it with 6-month score. METHODS: The treatment outcome of 300 patients with carpal tunnel decompression was determined by using Levine score at 2 weeks and 6 months after surgery. The mean age of patients was 56 years, 71% (214) were women, and 55% (167) of operations were performed on the right hand. All patients were scored using the Levine questionnaire preoperatively and at 2 weeks and 6 months from date of surgery. The correlation between the scores was evaluated. RESULTS: Although statistical significance was found between the preoperative score and the scores at both 2 weeks and 6 months, no statistical difference was found between the scores at 2 weeks and 6 months after surgery. Multiple regression analysis with the 2 week-6 month score difference as the dependent variable shows a predictable outcome at 2 weeks. CONCLUSIONS: We conclude that the Levine score at 2 weeks is a reliable, responsive, and practical instrument for outcome measure in carpal tunnel surgery. It coincides with suture removal and provides a convenient and predictive assessment of the medium-term results in a high percentage of treated patients. We conclude that the 2 time points, 2 weeks and 6 months, are equivalent in outcome because a less than 10-point difference is not clinically meaningful.     

Median nerve injury from local steroid injection in carpal tunnel syndrome

Local steroid injections for symptomatic relief of carpal tunnel syndrome have become common in the evaluation and treatment of this disorder; yet reports of median nerve injection injury from this practice are rare. We present a case of nerve injury from a steroid injection in a 24-year-old man with carpal tunnel syndrome that was successfully treated by division of the transverse carpal ligament and neurolysis. The histopathological characteristics of the lesion are presented, and the pathogenesis and treatment of this injury are discussed. Means of avoiding this complication include careful attention to anatomic landmarks as well as to the patient's subjective response during injection and avoidance of the use of local anesthetics.     

Biochemical evaluation of serum and flexor tenosynovium in carpal tunnel syndrome

In total, 41 consecutive patients with "idiopathic carpal tunnel syndrome" and abnormal electrophysiologic findings who underwent carpal tunnel release were studied prospectively. The focus of this investigation was the evaluation of the levels of specific chemical mediators within the serum and flexor tenosynovium of these patients. Blood was collected from these patients within 1 week prior to carpal tunnel release, and flexor tenosynovium was obtained at time of surgery. Specimens were then analyzed to determine the levels of interleukins 1 and 6, prostaglandin E(2) (PGE(2)), and malondialdehyde bis diethyl acetal. These values were compared to those of controls who had no evidence of carpal tunnel syndrome. A significant increase was noted in the serum malondialdehyde and tenosynovial levels of malondialdehyde, interleukin 6, and prostaglandin PGE(2) compared to controls. The elevated levels of these biologic factors and the absence of interleukin 1 elevation support a noninflammatory ischemia-reperfusion etiology for so-called "idiopathic carpal tunnel syndrome" that causes progressive edema and fibrosis of the tissues within the carpal canal. These findings correlate with previous histopathology reports. We believe that "idiopathic carpal tunnel syndrome" is an "-osis" not an "-itis."     

The influence of age on outcome after operation for the carpal tunnel syndrome. A prospective study

Decompression of the carpal tunnel is a common surgical procedure. Although the incidence of the carpal tunnel syndrome increases with age, there is no clear information available on the outcome of surgery in relation to age. We studied prospectively 87 consecutive patients who underwent decompression, using a validated self-administered questionnaire, and found that improvement in symptoms and function decreased with increasing age. This was most marked in patients over the age of sixty years.