Persistent median artery in the carpal tunnel: color Doppler ultrasonographic findings.

OBJECTIVE: To describe the ultrasonographic and color Doppler ultrasonographic findings in 2 patients with carpal tunnel syndrome associated with a persistent median artery and to report the frequency of this anatomic variation in healthy volunteers. METHODS: Two patients with the clinical appearance of carpal tunnel syndrome and 100 wrists and distal forearms of 50 asymptomatic volunteers were examined with ultrasonography and color Doppler ultrasonography. The frequency and size of a persistent median artery and its relationship to median nerve anatomy in the carpal tunnel were evaluated. RESULTS: A large persistent median artery of 3 mm in diameter was found in the affected hands in both patients with carpal tunnel syndrome. Findings were confirmed at surgery. Among the asymptomatic volunteers, a persistent median artery could be found in 13 (26%, 10 [20%] unilateral and 3 [6%] bilateral), with a mean diameter of 1.1 mm (range, 0.5-1.7 mm). In 10 (63%) of 16 hands, the persistent median artery was associated with high division of the median nerve or a bifid nerve configuration in the carpal tunnel. CONCLUSIONS: A persistent median artery is a common condition in healthy individuals and in most cases is related to median nerve variations such as high division or a bifid nerve. Because a persistent median artery has a superficial course close to the transverse carpal ligament, preoperative diagnosis of this anatomic variation may be of clinical importance.     

In-continuity neuroma of the median nerve after surgical release for carpal tunnel syndrome: case report

Iatrogenic injuries of the median nerve after surgical release for carpal tunnel syndrome resulting in the formation of a neuroma are rare. We present here the case of two patients, one with a bifid median nerve, showing in-continuity neuroma after surgical release for carpal tunnel syndrome. The patients reported persistent post-operative pain and showing symptoms. In both cases, ultrasound showed an in-continuity neuroma with a hypoechoic and enlarged median nerve at the carpal tunnel. The case report shows that ultrasound may be helpful in confirming the clinical diagnosis of neuroma and it is useful for evaluation of the percentage of the area affected by the tear.     

Bifid Median Nerve in Patients With Carpal Tunnel Syndrome

Objective. The aim of this study was to investigate the frequency of the anatomic variation of a bifid median nerve in patients with carpal tunnel syndrome (CTS) and to determine the size criteria for sonography. Methods. On axial sonograms of 320 hands of 170 patients with CTS and 240 hands of 120 unaffected individuals, the median nerve was evaluated morphologically for a bifid median nerve, and the cross‐sectional area was measured at 3 levels (radial‐ulnar junction, pisiform, and hook of the hamate). Electrophysiologic studies were performed in addition to clinical and sonographic evaluations in all patients, controls with a bifid median nerve, and controls with a cross‐sectional area of greater than 0.09 cm². Results. A bifid median nerve was seen in 32 (19%) of 170 patients and 11 (9%) of 120 controls. It occurred relatively frequently in patients with CTS (P < .01). The cross‐sectional area of the bifid median nerve was relatively higher than that of the nonbifid median nerve in controls at 2 of the 3 levels (P < .001; P = .226; P < .01). The cutoff values for the cross‐sectional area at the level of the pisiform were 0.11 cm² (sensitivity, 90%; specificity, 99%; P < .001) for patients with a bifid median nerve and 0.10 cm² (sensitivity, 98%; specificity, 81%; P < .001) for patients with a nonbifid median nerve. Conclusions. A bifid median nerve occurs relatively frequently in patients with CTS. It may facilitate compression of the median nerve in the carpal tunnel because of its relatively higher cross‐sectional area compared with a nonbifid median nerve. The size criterion for CTS in patients with a bifid median nerve is slightly higher than in those with a nonbifid median nerve.     

Sonographic diagnosis of anatomical variations associated with carpal tunnel syndrome

Bifid median nerve is an anatomic variation that occurs in about 18% of patients with symptoms suggestive of carpal tunnel syndrome and in about 15% of symptom‐free subjects. Reversed palmaris longus is a rare anatomic muscular variation. The simultaneous presence of a bifid median nerve and a reversed palmaris longus has been very rarely described, usually during surgical exploration or in cadavers. We present two cases where ultrasound showed the presence of both abnormalities, allowing a correct diagnosis and influencing the treatment plan. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42 :371–374, 2014     

High-resolution ultrasonography of the carpal tunnel

Twenty-eight wrists of 25 patients with carpal tunnel syndrome (CTS) and 28 wrists of 14 normal control subjects were studied with high-frequency real-time ultrasonography. Three general findings could be observed in CTS, regardless of its cause: swelling of the median nerve at the entrance of the carpal tunnel; flattening of the median nerve in the distal carpal tunnel; and increased palmar flexion of the transverse carpal ligament. Quantitative analysis proved these findings to be significant. We conclude that high-resolution sonography is able to diagnose median nerve compression in the carpal tunnel syndrome and to detect some of its potential causes.     

Nerve Echogenicity: Changes in High-Resolution Nerve Ultrasound in Carpal Tunnel Syndrome after Surgery

The aim of our prospective study was to detect changes in nerve echogenicity of the median nerve before and after successful surgery in patients with carpal tunnel syndrome (CTS) using high-resolution ultrasound. Fifteen patients with a definite diagnosis of CTS who underwent surgery were scanned by one examiner with high-resolution ultrasound, and images were analyzed by two blinded raters using ImageJ to assess the echogenicity of the median nerve (fraction of black) with a semiautomated thresholding technique before and 3 mo after surgery compared with 15 controls. In CTS patients, nerve echogenicity before surgery was significantly lower compared with that of controls (fraction of black: mean 63.9 vs. 44.6, p < 0.0001). Three months after surgery nerve echogenicity significantly increased (fraction of black was lower, mean 55.5; p < 0.0001) as a possible sign of reduction of intraneural edema, but did not reach the values of healthy controls. Semi-automated evaluation of the echogenicity of the median nerve may be used as a marker of successful carpal tunnel release. Further studies are warranted to detect how nerve echogenicity changes after unsuccessful carpal tunnel release.     

高频超声对ECTR术后神经解剖学参数的动态评估价值

目的 探讨高频超声对关节镜下腕管松解术后神经解剖学参数的动态评估价值。方法 随访31例（44腕）腕管综合症患者术前3天,术后2周、4周、3月、6月、1年正中神经卡压近端水肿范围、腕管入口正中神经直径及横截面积,并根据横截面积绘制高频超声诊断腕管综合征ROC曲线。结果 术后各神经解剖学参数逐步改善,术后1个月至3个月各解剖学参数改善最明显。高频超声对CTS具有较高的诊断效能。结论 高频超声能够对关节镜下腕管松解术后神经解剖学参数进行有效地的动态评估。     

腕管综合征和肘管综合征的超声影像学研究

目的探讨超声在腕管综合征和肘管综合征中的诊断价值。方法80例健康者为对照组,临床疑诊27例腕管综合征和32例肘管综合征患者,超声测量其正中神经、尺神经的前后径、左右径及横截面积,同时测定神经传导速度。结果腕管综合征和肘管综合征组正中神经、尺神经的前后径、左右径及横截面积均大于对照组（P〈0．01）,腕管综合征和肘管综合征组的病变神经横截面积均与运动传导速度呈负相关（r分别为-0．76、-0．80）。结论超声可为腕管综合征和肘管综合征的诊断提供影像学依据,并对其治疗及疗效评价有重要价值。     

Chronic carpal tunnel syndrome caused by covert tophaceous gout: A case report

Carpal tunnel syndrome (CTS) is well recognized as the most common type of peripheral neuropathy. A rare cause of CTS is tophaceous gout. Tophi deposits can accumulate in various structures including the flexor tendons, tendon sheaths, the carpal tunnel floor, transverse carpal ligament, and even the median nerve, causing various symptoms such as pain, numbness, and weakness. Tophi forming in the carpal canal can compress the median nerve, leading to CTS. Here, we describe a 25-year-old male with a family history of tophaceous gout who presented with typical CTS symptoms. Although he had chronic numbness in his right hand, he failed to present with any obvious palpable masses on his forearm or hand. However, his family history, laboratory, clinical, and magnetic resonance imaging findings were consistent with tophi deposits. CTS symptoms were eased through surgical removal of tophi and decompression of the median nerve. No recurrences of gout and CTS symptoms were reported at a one-year follow-up. This case shows that CTS symptoms could be the initial manifestation of tophaceous gout. In patients with a family history of gout and with CTS symptoms, imaging examinations are critical for early diagnosis and selecting appropriate treatment. Surgical removal of “covert” tophi and decompression of the median nerve is an effective option for eliminating symptoms.     

Enhancement in median nerve mobility during radioulnar wrist compression in carpal tunnel syndrome patients

BackgroundCarpal tunnel syndrome is a compression neuropathy at the wrist associated with compromised median nerve mobility. The purpose of this study was to investigate the effects of radioulnar wrist compression on median nerve longitudinal mobility within the carpal tunnel in carpal tunnel syndrome patients as well as healthy subjects.MethodsDynamic ultrasound images captured longitudinal median nerve motion in the carpal tunnel during radioulnar wrist compression force application in 11 healthy subjects and 11 carpal tunnel syndrome patients.FindingsWe found that median nerve mobility was not significantly affected by radioulnar wrist compression in healthy subjects (P = 0.34), but improved by 10 N radioulnar wrist compression in carpal tunnel syndrome patients (P < 0.05). Analysis of segmental median nerve mobility in carpal tunnel syndrome patients showed significantly improved mobility in the proximal tunnel section under 10 N radioulnar wrist compression force condition compared to the no compression condition (P < 0.05).InterpretationModerate radioulnar wrist compression force application helps restore impaired median nerve mobility and may be effective in improve nerve function and symptoms associated with carpal tunnel syndrome.     

Early results of surgical treatment for carpal tunnel syndrome using a single-portal endoscopic method

Background. Carpal tunnel syndrome, the most common peripheral neuropathy, is caused by increased carpal tunnel pressure and decreased carpal tunnel volume. The aim of our study was to evaluate early results in single-portal endoscopic carpal tunnel release for the surgical treatment of carpal tunnel syndrome. Material and methods. The population included 67 patients with 80 hands operated using single-portal endoscopic carpal tunnel release. The sample included in this study consisted of 45 patients (67% of the total) and 56 hands (70%). In order to assess surgical outcome, we used the patients' subjective evaluation, the results of the Carpal Tunnel Syndrome Symptom Severity Scale and the Carpal Tunnel Syndrome Functional Status Scale, data acquired during anamnesis and physical examinations, and the results of electromyography tests. Results. In 49 cases (88%) the results were rated subjectively as good or excellent, in 6 cases (11%) satisfactory, and in 1 case (2%) unsatisfactory. At follow-up 12 months after surgery the results from the Carpal Tunnel Syndrome Symptom Severity Scale ranged from 1.2 to 3.64 (mean 1.55), and on the Carpal Tunnel Syndrome Functional Status Scale from 1.12 to 3.71 (mean 1.66). Conclusions. Single-portal endoscopic carpal tunnel release gives good results in the surgical treatment of carpal tunnel syndrome among patients diagnosed with grade I or grade II CTS, and in those groups of patients for whom revision surgery is not planned, tenosynovectomy is not indicated, and there is no need to inspect the motor branch of the median nerve.     

Carpal tunnel pressure measurement during two-portal endoscopic carpal tunnel release

Background

Although there remain concerns of median nerve damage during endoscopic carpal tunnel release for carpal tunnel syndrome, carpal tunnel pressure variations during Chow's two-portal techinique have not been well investigated.

Methods

We performed a modified two-portal endoscopic carpal tunnel release on 30 patients by inserting a catheter pressure transducer into the carpal tunnel for continuous pressure measurement during the procedure. Grip and pinch strengths, Semmes–Weinstein monofilament test, and nerve conduction studies were examined preoperatively and at postoperative 1, 3, and 6 months. Numbness and the Disabilities of the Arm, Shoulder and Hand score were also evaluated pre and postoperatively.

Findings

Subjective symptoms and nerve conduction study findings improved uneventfully. The pressure was always observed to be maximum pressure immediately before the cannula was withdrawn from the exit portal, and carpal tunnel pressure > 300 mm Hg was recorded in most of the patients.

Interpretation

A transient increase in the carpal tunnel pressure occurred in all the patients; however, it did not correlate with their clinical outcome or with increased risk of peri-operative complications. Since time–pressure threshold of the median nerve during endoscopic carpal tunnel release is still unknown, our results did not guarantee its safety.     

Familial bilateral carpal tunnel syndrome: report of two families.

Cases of familial carpal tunnel syndrome without other associated conditions are rare. We report two families in which multiple members had bilateral carpal tunnel syndromes. The pattern was consistent with autosomal dominant inheritance. Electrophysiologic studies were performed on nine of the 15 patients, and they demonstrated bilateral pathology of the median nerves at the wrist in all but one patient, without evidence for subclinical, generalized peripheral neuropathy. Quantitative sensory testing was performed in two cases, and it corroborated the absence of peripheral neuropathy. Five of the six patients who underwent carpal tunnel release improved after surgery.     

Congenital carpal tunnel syndrome: case report of autosomal dominant inheritance and review of the literature

Carpal tunnel syndrome (CTS) is unusual in childhood, and familial occurrence has been reported infrequently. A case of CTS in a seven-year-old boy, associated with abnormal thickening of the transverse carpal ligament and aplasia of the median nerve distal to this ligament, is described. Clinical, electrodiagnostic, and surgical findings are presented: all were consistent with absence of the median nerve distal to the transverse carpal ligament. Family history of CTS was positive in a pattern consistent with autosomal dominant transmission in three generations. Thickening of the transverse carpal ligament has been described, although infrequently, in childhood and familial CTS. Aplasia of the median nerve distally has not been reported in association with this anatomic abnormality. Case reports of familial CTS are reviewed, and other congenital anomalies which should be considered in the differential diagnosis of CTS in children and adults are discussed.     

On the Challenges Associated with Obtaining Reproducible Measurements Using SWEI in the Median Nerve

This work discusses challenges we have encountered in acquiring reproducible measurements of shear wave speed (SWS) in the median nerve and suggests methods for improving reproducibility. First, procedural acquisition challenges are described, including nerve echogenicity, transducer pressure and transmit focal depth. Second, we present an iterative, radon sum–based algorithm that was developed specifically for measuring the SWS in median nerves. SWSs were measured using single track location shear wave elasticity imaging (SWEI) in the median nerves of six healthy volunteers and six patients diagnosed with carpal tunnel syndrome. Unsuccessful measurements were associated with several challenges including reverberation artifacts, low signal-to-noise ratio and temporal window limitations for tracking the velocity wave. To address these challenges, an iterative convergence algorithm was implemented to identify an appropriate temporal processing window that removed the reverberation artifacts while preserving shear wave signals. Algorithmically, it was important to consider the lateral regression kernel size and position and the temporal window. Procedurally, both nerve echogenicity and transducer compression were determined to impact the measured SWS. Shear waves were successfully measured in the median nerve proximal to the carpal tunnel, but SWEI measurements were significantly compromised within the carpal tunnel itself. The velocity-based SWSs were statistically significantly higher than the displacement SWSs (p < 0.0001), demonstrating for the first time dispersion in the median nerve in vivo using SWEI.     

Effects of Neuromobilization Maneuver on Clinical and Electrophysiological Measures of Patients with Carpal Tunnel Syndrome

[Purpose] The aim of this study was to investigate the efficacy of neuromobilization combined with routine physiotherapy in patients with carpal tunnel syndrome through subjective, physical, and electrophysiological studies. [Subjects and Methods] Twenty patients with carpal tunnel syndrome (totally 32 hands) were assigned two groups: treatment and control groups. In both groups, patients received the routine physiotherapy. In addition to the routine physiotherapy, patients in the treatment group received neuromobilization. The symptoms severity scale, visual analogue scale, functional status scale, Phalen’s sign, median nerve tension test, and median nerve distal sensory and motor latency were assessed. [Results] There were significant improvements in the symptoms severity scale, visual analogue scale, median nerve tension test, and Phalen’s sign in both groups. However, the functional status scale and median nerve distal motor latency were significantly improved only in the treatment group. [Conclusion] Neuromobilization in combination with routine physiotherapy improves some clinical findings more effectively than routine physiotherapy. Therefore, this combination can be used as an alternative effective non-invasive treatment for patients with carpal tunnel syndrome.Key words: Carpal tunnel syndrome, Neuromobilization, Electrophysiological measures     

Carpal tunnel syndrome, subclinical median mononeuropathy, and peripheral polyneuropathy: common early complications of chronic peritoneal dialysis and hemodialysis.

Nerve conduction velocity studies were done in median, ulnar, and peroneal nerves, one time each in 46 patients who had been on chronic peritoneal dialysis or hemodialysis for varying lengths of time. Only six patients had normal findings; 37 had peripheral polyneuropathy (15 had isolated polyneuropathy; 22 had median nerve dysfunction in addition); 16 had subclinical median mononeuropathy (14 with polyneuropathy, two without); and nine had overt carpal tunnel syndrome (eight with polyneuropathy, one without). Abnormalities were present in seven of the 11 patients studied after one year of dialysis and in 19 of the 24 patients studied after two years of dialysis. Seventeen patients studied after five years of dialysis all had polyneuropathy. Nine patients studied after seven years of dialysis all had median nerve dysfunction. Abnormalities were as common with peritoneal dialysis as with hemodialysis. Nerve dysfunction was independent of the disease underlying renal failure, the side of the dialysis access shunt, and the presence or absence of osteodystrophy. Dialysis patients need frequent nerve conduction studies from the onset of dialysis to identify carpal tunnel syndrome early and to avoid irreversible nerve damage.     

超声对腕管综合征和肘管综合征的诊断价值

目的探讨超声对腕管综合征、肘管综合征的诊断价值。方法 25例体检健康者为对照组,临床疑诊35例腕管综合征和22例尺神经卡压患者为病变组,超声探查正中神经豌豆骨水平横断面积及其前后径(D1)、钩骨勾水平前后径(D2)、钩骨勾水平远端前后径(D3),肘部尺神经横断面积,计算D1与D2差值(D),D3与D2差值(d),将病变组超声检查结果与术中所见进行比较。结果超声可显示正中神经、尺神经卡压后的形态变化,病变组正中神经横断面积、D、d及尺神经横断面积均大于对照组(P0.03)。与术中所见比较,超声诊断腕管综合征、肘管综合征准确率分别为97.9%、95.4%。结论超声能有效诊断腕管综合征和肘管综合征。     

Acute calcifying tendonitis--an unusual cause of carpal tunnel syndrome.

We report a rare case of acute calcifying tendinitis resulting in acute carpal tunnel syndrome. Acute medical staff should be aware of this condition and the importance of early referral to avoid long term median nerve neuropathy.     

"Tethered" median nerve stress test in chronic carpal tunnel syndrome

Tension of the median nerve produced by simultaneous extension of the supinated wrist and distal interphalangeal joint of the index finger was noted to result in proximal volar forearm pain radiation in patients with chronic carpal tunnel syndrome. This sign was less frequent in patients with a more acute syndrome. Adhesions between the median nerve and the overlying transverse carpal ligament and the development of a pseudoneuroma can individually or together occur in the chronic carpal tunnel syndrome limiting distal nerve excursion of the tethered nerve during simultaneous wrist and index finger extension.