超声引导下正中神经阻滞对腕管综合征治疗效果的影响

目的观察超声引导下正中神经阻滞治疗腕管综合征的临床效果。方法选择40例(69个患腕)腕管综合征患者,性别不限,年龄33~61岁,ASAⅠ或Ⅱ级。随机分为超声组(U组)和对照组(C组),每组20例。U组采用超声引导下正中神经阻滞,C组采用解剖标志定位正中神经阻滞,两组每次阻滞药物均为布比卡因4.5mg、曲安奈德5mg、维生素B12 100μg混合液3ml。通过Boston腕管问卷调查表(BCTQ)评估患者治疗前后手症状和功能;记录治疗前后正中神经电生理参数;记录二次治疗及不良反应情况。结果与治疗前比较,治疗后1个月两组BCTQ评分中的症状严重程度评分(SSS)和功能状态评分(FSS)明显降低(P0.05),且U组SSS明显低于C组(P0.05),两组FSS差异无统计学意义。与治疗前比较,治疗后1个月两组运动潜伏期(MDL)、感觉潜伏期(SDL3)明显缩短(P0.05),感觉神经传导速度(SNCV)明显增快(P0.05),而运动神经传导速度(MNCV)差异无统计学意义。治疗后1个月,U组SNCV明显快于C组(P0.05),其余神经电生理参数两组差异无统计学意义。U组二次治疗及不良反应明显少于C组(P0.05)。结论采用超声引导下神经阻滞治疗腕管综合征能显著改善患者的手部症状,减少并发症。     

Bilateral carpal tunnel syndrome with anomalous palmaris profundus tendons

Abstract

This report presents the case of a 44-year-old man who presented with elective bilateral carpal tunnel decompression. At the operation, he was found to have bilateral palmaris profundus tendons within the carpal tunnel, impinging on the median nerve. In releasing both carpal tunnels, the patient's symptoms were alleviated and there was regain of full function. There have been very few documented cases of these anomalous tendons implicated in carpal tunnel syndrome and this case highlights how such anatomical variations are important in the surgical approach to carpal tunnel decompression.     

Bilateral palmaris profundus in association with bifid median nerve as a cause of failed carpal tunnel release

This is a case in which an anomalous tendon of the palmaris profundus was found running on the anterior surface of the median nerve, dividing the nerve into 2 branches at the wrist bilaterally. Excision of the tendon at the time of re-exploration of the carpal tunnel resulted in complete relief of carpal tunnel symptoms.     

Bifid median nerve as a determinant of carpal tunnel syndrome recurrence after endoscopic procedures. A case report

A number of complications have been associated with endoscopic technique in treating carpal tunnel syndrome (CTS). We observed a female patient who had previously undergone endoscopic surgery for CTS. Shortly after surgery, this patient complained of pain, numbness and strength deficiency, as severe as it was before the operation. A new, open, surgical procedure was performed. During this second-look surgery, we found a bifid median nerve, which divided into two branches at the second third of the forearm, proximal to the flexor retinaculum. We strongly suggest a careful exploration of the median nerve in the carpal tunnel. Moreover, we believe that an extensive preoperative assessment of median nerve morphology and function is mandatory prior to endoscopic approach in treating CTS.     

108例腕管综合征正中神经传导测定结果分析

分析１０８例腕管综合征正中神经传导测定结果，以求最敏感的电诊断指标。比较１０８例正中神经复合肌肉动作电位，肘至腕的运动传导速度测定及指至腕部的感觉神经动作电位三项。指标异常检测率，表明拇指至腕段的感觉传导速度减慢是最敏感的电诊断参量。１０８例中伴有前臂段运动传导速度减慢的占１０．５％。同组病例无症状上肢出现电生理异常者为２０％，指示有亚临床的腕管部神经卡压存在的可能。     

Results of treatment of carpal tunnel syndrome with associated hourglass deformity of the median nerve

Two hundred twenty-seven successive cases of carpal tunnel syndrome confirmed by abnormal electrodiagnostic studies were reviewed. All cases underwent open carpal tunnel release by a single surgeon over a 3-year period. Thirty-two hands (14% of all cases) in 29 patients demonstrated an hourglass deformity at the time of surgery. Electrodiagnostic tests revealed no evidence of any other type of peripheral neuropathy in any patient. Postoperative electrodiagnostic studies were obtained in all cases on completion of therapy. The length of the follow-up period averaged 11 months (range, 3-35 months). The duration of preoperative symptoms ranged from 2 years to more than 10 years. Twenty-eight of the 32 hands (88%) with hourglass deformities demonstrated subjective clinical improvement or complete resolution of symptoms. Chronicity of symptoms and electrophysiologic severity did not correlate with the presence of the hourglass deformity. Presence of hourglass compression of the median nerve in carpal tunnel syndrome is therefore not a negative prognostic indicator.     

Carpal tunnel syndrome due to fibrolipomatous hamartoma of the median nerve

Nervous lipofibromatous hamartoma is a rare tumor-like condition involving the peripheral nerves, whereby the epineurium and perineurium are enlarged and distorted by excess of fatty and fibrous tissues that infiltrate between and around nerve boundaries. The median nerve is much more likely to develop a hamartoma than other nerves with a predilection for the carpal tunnel. We present a case of carpal tunnel syndrome in an adult caused by fibrolipomatous hamartoma of the median nerve, successfully removed by excision of the fibrolipomatous tissue and decompression.     

Intraoperative electroneurography during median nerve decompression in carpal tunnel syndrome

Summary In 17 patients with the diagnosis of carpal tunnel syndrome, orthodromic sensory nerve conduction measurements during ligament division and internal neurolysis were performed without the use of a pneumatic tourniquet. While ligament division led to an increase in conduction velocity (p < 0.05; median increase 0.7 m/s), it did not result in a significant change of the amplitude. During internal neurolysis, an increase of the sensory nerve potential (p<0.01; median increase 0.9 V) and no significant change in conduction velocity were observed. We conclude that internal neurolysis does not cause a disruption of nerve function during the operation.     

Ultrasonographic median nerve changes under tendon gliding exercise in patients with carpal tunnel syndrome and healthy controls

Study designCase control study.Purpose of the studyTo evaluate the ultrasonographic median nerve changes under tendon gliding exercise in patients with carpal tunnel syndrome (CTS) and healthy controls.MethodsSeventy-three patients with CTS and 53 healthy volunteers were consecutively recruited. Each subject underwent a physical examination, nerve conduction studies and ultrasonographic examinations of the median nerve during tendon gliding exercises.ResultsSignificant changes in the cross-sectional area of the median nerve were found while moving from the straight position to the hook position and from the hook position to the fist position. There were also significant changes in the flattening ratio when moving from the hook position to the fist position.ConclusionsUltrasonography revealed that the median nerve was compressed in the fist position in both CTS patients and healthy volunteers. Thus, forceful grasping should be avoided during tendon gliding exercises performed in the fist position.Level of evidence3b     

Carpal arch and median nerve changes during radioulnar wrist compression in carpal tunnel syndrome patients

The purpose of this study was to investigate the morphological changes of the carpal arch and median nerve during the application of radiounlarly directed compressive force across the wrist in patients with carpal tunnel syndrome. Radioulnar compressive forces of 10 N and 20 N were applied at the distal level of the carpal tunnel in 10 female patients diagnosed with carpal tunnel syndrome. Immediately prior to force application and after 3 min of application, ultrasound images of the distal carpal tunnel were obtained. It was found that applying force across the wrist decreased the carpal arch width (p < 0.001) and resulted in increased carpal arch height (p < 0.01), increased carpal arch curvature (p < 0.001), and increased radial distribution of the carpal arch area (p < 0.05). It was also shown that wrist compression reduced the flattening of the median nerve, as indicated by changes in the nerve's circularity and flattening ratio (p < 0.001). This study demonstrated that the carpal arch can be non‐invasively augmented by applying compressive force across the wrist, and that this strategy may decompress the median nerve providing symptom relief to patients with carpal tunnel syndrome. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1234–1240, 2016.     

Acute carpal tunnel syndrome as a result of spontaneous bleeding

Acute carpal tunnel syndrome is the most common compression neuropathy of the upper extremity following trauma. A rare occurence of spontaneous bleeding into the carpal tunnel, presenting as acute carpal tunnel syndrome, is presented.     

Carpal tunnel pressure alters median nerve function in a dose-dependent manner: a rabbit model for carpal tunnel syndrome.

BACKGROUND: An in vivo animal model for carpal tunnel syndrome (CTS) is presented which allows for graded application of pressure to the median nerve within the carpal canal. We hypothesized that such pressure would cause electrophysiologic changes in the median nerve in a dose-related manner, with NCS/EMG changes consistent with CTS in humans. METHODS: In 40 New Zealand white rabbits, ranging from 2 to 2.5 kg, angioplasty catheters were placed in the carpal tunnel in the forepaws and pressures ranging from 50 to 80 mmHg applied to one side while the contralateral side served as the control and remained uninflated. Pressure was applied until a 15% increase in distal motor latency was obtained for 2 consecutive weeks by nerve conduction studies. RESULTS: All the experimental limbs exhibited a 15% increase in distal motor latency. None of the control limbs showed a significant increase in distal motor latency. In the experimental animals the 15% delay was achieved in approximately 4-5 weeks in the 50-70 mmHg groups and in approximately 1 week in the 80 mmHg group. CONCLUSION: This new animal model for CTS demonstrates a direct cause and effect relationship between carpal tunnel pressure and median nerve dysfunction. We anticipate that this in vivo model with clinically relevant outcomes will facilitate identification of injury mechanisms, and will serve as a basis for future development of novel interventions and treatments.     

The anatomical site of constriction of the median nerve in patients with severe idiopathic carpal tunnel syndrome

During open carpal tunnel release in patients with severe idiopathic carpal tunnel syndrome, an area of constriction in the substance of the median nerve is frequently noted. In a prospective study of 30 patients, the central point of the constricted part of the nerve was determined intraoperatively and found to be, on average, 2.5 (range 2.2-2.8)cm from the distal wrist crease. This point always corresponded to the location of the hook of the hamate bone. These intraoperative findings were compared with the "narrowest" point of the carpal canal as determined by anatomical and radiological studies in the literature.     

Aberrant radial artery seen in the carpal tunnel at carpal tunnel decompression: case report

We present a case in which the radial artery was found running within the carpal tunnel at the time of routine carpal tunnel decompression. It appears to be an anomalous superficial palmar branch of the radial artery that is substituting for the normal radial artery.     

Lipofibromatous hamartoma of the median nerve in patients with macrodactyly: diagnosis and treatment of a rare disease causing carpal tunnel syndrome

Lipofibromatous hamartoma is a very rare benign peripheral nerve tumour. It is mostly encountered in the proximal extremities of young adults, involving the median nerve in the majority of cases. We present two patients with macrodactyly and carpal tunnel syndrome caused by lipofibromatous hamartoma of the median nerve and discuss diagnosis and treatment of the disease. A 10-year-old girl with a congenital progressive macrodactyly of her right index finger presented with a slowly growing mass in her right palm and pain and numbness, along with motor and sensory deficits in the median nerve distribution. Treatment consisted of carpal tunnel release, epineurolysis and partial excision of the fibrofatty tissue. The second patient, a 25-year-old man presented with a swelling in his left palm and findings compatible with carpal tunnel syndrome. Intraoperatively, the lesion presented as sausage-shaped enlargement of the median nerve by fibrofatty tissue. After carpal tunnel release, a partial excision of the mass with epineurolysis was performed. In both patients, histology showed nerve bundles separated by abundant fibrofatty tissue. In the girl, a proliferation of dysplastic perineurial cells could be observed. The suspected diagnosis for patients with macrodactyly and clinical signs of carpal tunnel syndrome should be lipofibromatous hamartoma. A carefully taken history, physical examination, X-ray, and MRI are important for its correct diagnosis. The surgical management remains controversial. Treatment should include decompression of the median nerve at points of compression, partial excision of the fibrofatty tissue, and debulking of soft tissue. In some cases, an epineurolysis can be additionally performed.     

Evaluation of sensory function after median nerve decompression in carpal tunnel syndrome using the current perception threshold test

The recovery level for sensory function after carpal tunnel release for the treatment of idiopathic carpal tunnel syndrome (CTS) was assessed with the current perception threshold (CPT) test. Seventeen CTS patients (21 hands) were followed, and the CPTs at the index finger of each patient was measured preoperatively and at 1, 3, and 6 months postoperatively. After carpal tunnel release, there was significant recovery of CPT at all stimulation frequencies, indicating improvement of all sensory functions including sensations of temperature, pain, touch, and vibration.     

Neurothekeoma of the median nerve: case report

We report the case of a large intraneural neurothekeoma of the median nerve at the wrist. Neurothekeomas are rare; they are small, superficial, and typically asymptomatic benign tumors of undetermined cellular origin. Complete excision is usually curative. This case is interesting owing to the tumor's large size and location within the median nerve, which made it highly symptomatic, mimicking carpal tunnel syndrome.