Carpal tunnel pressure in patients with carpal tunnel syndrome due to long-term hemodialysis

We studied carpal tunnel pressure and outcome of endoscopic carpal tunnel release in 42 patients (53 hands) with carpal tunnel syndrome (CTS) and receiving long-term hemodialysis. We compared these results with those of 41 patients (49 hands) with idiopathic CTS. Pressure was measured peroperatively: first, before dilation of the carpal tunnel; second, after dilation but before release of the transverse carpal ligament; and third, after completion of the release. In patients receiving long-term hemodialysis, the highest pressures were 76.9, 56.0, and 7.8 mmHg respectively. In patients with idiopathic CTS, pressures were 68.8, 44.1, and 4.0 mmHg respectively. The clinical outcome was inferior in patients receiving long-term hemodialysis.     

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.     

Patient-reported outcome after carpal tunnel release for advanced disease: a prospective and longitudinal assessment in patients older than age 70

PURPOSE: Advanced stages of nerve compression are likely to result in irreversible intraneural changes including intrinsic fibrosis and axon loss, and advanced age is expected to compromise nerve regeneration and recovery. Although satisfactory outcomes have been reported we hypothesized that carpal tunnel release in an elderly population with advanced carpal tunnel disease might not significantly improve symptom severity, functional status, or grip strength compared with before surgery. Our purpose was to evaluate these 3 parameters both before and after surgery to assess the efficacy of surgical intervention. METHODS: Between October 2000 and January 2002 a total of 13 patients (14 hands) were enrolled into a prospective longitudinal study. Entry criteria included advanced carpal tunnel syndrome based on neurophysiologic studies (absent sensory latencies and positive fibrillation potentials), clinical examination (thenar atrophy), and age over 70 years. Exclusion criteria included cervical disease, prior surgery, concomitant surgery, diabetic neuropathy, and associated cubital tunnel syndrome. There were 7 men and 6 women with an average age of 79 years (range, 72-90 y). With the help of a neutral observer each patient completed the Brigham and Women's validated carpal tunnel syndrome questionnaire before and 6 and 12 months after surgery to assess symptom severity and functional status. Grip strength was measured before and at 1 year after surgery and each patient also was asked to rate their level of satisfaction with their outcome at 1 year after surgery. RESULTS: Before surgery the mean symptom severity score was 29 based on a scale in which a minimum score of 11 reflects no symptoms and a maximum score of 55 reflects severe symptoms. The mean functional status score was 18 on a scale in which a minimum score of 8 reflects no difficulty and a high score of 40 reflects severe impairment. Six months after surgery the mean symptom severity score decreased from 29 to 15 (11 reflects no symptoms) and the average functional status score decreased from 18 to 11 (8 reflects no difficulty). One year after surgery the symptom severity score decreased from 15 to 14 and the functional status score decreased from 11 to 9. Compared with scores before surgery the improvements at 6 months and 1 year were statistically significant. Patient satisfaction was noted for 13 of 14 hands. Average grip strength remained unchanged after surgery. CONCLUSIONS: Carpal tunnel release is unlikely to result in a total elimination of symptoms and complete restoration of function when performed in elderly patients with advanced disease. Although grip strength did not improve at final follow-up evaluation, symptom severity and functional status did improve from the patient's perspective. We conclude that carpal tunnel release is efficacious in this subset of patients.     

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.     

Endoscopic release in carpal tunnel syndrome: analysis of clinical results in 200 cases.

Carpal tunnel syndrome is the most common peripheral neuropathy. Conventional carpal tunnel surgery has been performed as a primary procedure for the decompression of the median nerve at the wrist in patients who have idiopathic carpal tunnel syndrome. While the results have been excellent, this surgical procedure has been reported to be related to high postoperative morbidity and extended length of recovery time. Over the past decade, endoscopic release of the transverse carpal ligament has been developed as a new, alternative method to the open procedures. Endoscopic carpal tunnel release has been reported to ensure less postoperative morbidity, more rapid recovery of strength, with earlier return to work, reduced disability time and a better cosmetic result. The authors present a surgical series of 200 hands in 164 patients (36 bilaterals) with idiopathic carpal tunnel syndrome, who underwent a single-portal endoscopic carpal tunnel release (Agee technique), with regards to the clinical outcome and complications occurred after 4-months follow-up.     

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

Introduction The development of a carpal tunnel syndrome has become an increasingly recognized problem in patients who are treated by long-term hemodialysis. Arteriovenous fistula has been identified as one of the possible cause for the development of carpal tunnel syndrome. Materials and methods Wrists of 558 hemodialysis patients who had fistula at least 1 year served as the case group and the other intact wrists of the same patients served as the control group. Carpal tunnel syndrome was diagnosed clinically; however, 232 random patients underwent electrodiagnostic studies the day after hemodialysis. Results In 170 (30.5%) wrists with arteriovenous fistula developed carpal tunnel syndrome versus 68 (12.2%) in the contralateral wrist. Three patients had a concurrent diagnosed radial steal syndrome. In all three wrists that had radial steal syndrome developed carpal tunnel syndrome. There was a correlation, however, between the development of the carpal tunnel syndrome, and the side of the longest vascular access. Contrary to the clinical assessment, electrodiagnostic studies did not indicate any significant association between the frequency of carpal tunnel syndrome and arteriovenous fistula or its duration. Conclusion Hemodialysis patients are at considerable risk of developing carpal tunnel syndrome in the wrist with an arteriovenous fistula. Close observation and routine clinical examination is mandatory to prevent further problems.     

Differences in characteristics of carpal tunnel syndrome between male and female patients

BackgroundSex difference is known to be a risk factor of carpal tunnel syndrome. However, sex differences with regard to the clinical presentation of carpal tunnel syndrome have not received much attention. Thus, this study aimed to detect any difference in the characteristics of carpal tunnel syndrome between male and female and thereby add new insights into disease prevention.MethodsA total of 647 patients (male 193 hands and female 454 hands) with carpal tunnel syndrome who underwent endoscopic or open carpal tunnel release were retrospectively reviewed. The average age at time of surgery was 66 years. Clinical and electrophysiological data of all patients were collected. Six medical conditions, including trigger finger, diabetes mellitus, hemodialysis, hyperlipidemia, hypertension, and obesity were also investigated.ResultsA significant difference was found in the distribution of comorbidities between the male and female groups. Particularly, the prevalence of diabetes mellitus, hemodialysis, and hypertension were significantly higher in the male group than in the female group. Meanwhile, the presence of thenar muscle atrophy was significantly higher in the female group than in the male group.ConclusionsWomen are more likely to experience carpal tunnel syndrome even though they have no comorbidities. We suggest that carpal tunnel syndrome especially in male patients may be reduced by early intervention for diabetes mellitus. Prospective studies are needed to validate the causal relationship between diabetes mellitus and carpal tunnel syndrome.     

Endoscopic carpal tunnel release in the elderly.

The present study is aimed to clarify the postoperative outcome of endoscopic carpal tunnel release in elderly patients with carpal tunnel syndrome. Endoscopic carpal tunnel release was performed on 37 hands of 27 patients (2 men, 25 women) who were aged 70 years or older and clinically and electrophysiologically diagnosed with carpal tunnel syndrome. Mean age at the time of surgery was 74.5 years (range: 70-85 years). Mean postoperative follow-up was 35.5 months (range: 12-114 months). Pain was present preoperatively in 20 hands, but quickly resolved postoperatively in all cases. Numbness completely disappeared in 13 of 37 hands (35.1%), but some degree of numbness remained in the remaining cases. Preoperative severity of thenar muscle atrophy was none in 4 hands, mild in 7 hands, moderate in 12 hands and severe in 14 hands. Postoperative severity of thenar muscle atrophy at final follow-up was none in 13 hands, mild in 16 hands, moderate in 2 hands and severe in 6 hands, confirming that thenar muscle atrophy improves even in elderly patients. However, moderate or severe thenar muscle atrophy remained in 8 hands (21.6%). Endoscopic carpal tunnel release should be considered in the elderly, even though clinical symptoms may not improve substantially in advanced cases.     

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 associated with long-term hemodialysis: case report

Since Warren and Otieno reported carpal tunnel syndrome in patients on intermittent hemodialysis in 1975, a number of related reports have been published. However, there are few reports associated with neurosurgery about carpal tunnel syndrome in patients on long term hemodialysis. We reviewed this disease and reported our case. We treated a patient who complained of bilateral hand numbness and atrophy of the right thenar muscle. He had been suffering from chronic renal failure and had been treated with hemodialysis for ten years. We diagnosed carpal tunnel syndrome based on the findings concerning Tinel's sign, Phalen test, and the conduction velocity of the median nerve. We performed decompression surgery of the median nerve. However, although there was no recovery from thenar muscle atrophy, there was improvement of hand numbness. Histologically, amyloid deposits within the hypertrophic transverse carpal ligament on the right side, could be found but on the left side where the internal shunt had been made amyloid deposits were absent. The reason why patients receiving long term hemodialysis develop carpal tunnel syndrome is controversial, but it seems that beta 2 microglobulin may play an important role in developing carpal tunnel syndrome in hemodialysis patients. This was reported by Gejyo in 1985. There may be uremic and/or diabetic neuropathy in these patients, and these neuropathies may be responsible for the more rapid deterioration and poorer surgical results in carpal tunnel syndrome associated with hemodialysis than in idiopathic cases. It is most important that carpal tunnel syndrome has to be diagnosed early and that surgical decompression is performed while the disease is in its early stage.     

Outcome of carpal tunnel release in patients with normal nerve conduction studies

BackgroundWe evaluated outcome after carpal tunnel release (CTR) in patients with clinically diagnosed carpal tunnel syndrome (CTS) but normal results in nerve conduction studies (NCS), and compared these results with those from a prospective group of patients with NCS-verified CTS.MethodsOver a 5-year period, we prospectively included 103 patients with clinical CTS. NCS were done at inclusion, with surgeon and patient being kept blind regarding the result. The patients underwent endoscopic CTR. QuickDASH and satisfaction score were recorded preoperatively and 4 months after surgery. 94 patients, 47 of whom had NCS-verified CTS, completed the study.ResultsA significant improvement in QuickDASH score (18 and 20 points respectively, p < 0.01) was found for both groups. Satisfaction score was significantly higher in the group with NCS-verified CTS. However, the overall satisfaction rates were 87% in the normal NCS group and 95% in the group with abnormal NCS.ConclusionsClinical outcome after CTR in patients with normal NCS was favourable and similar to that obtained in patients with NCS-verified CTS. Nonetheless, patients with normal result in NCS gave a lower satisfaction score.     

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.     

Investigation of segmental carpal tunnel pressure in patients with idiopathic carpal tunnel syndrome--is it necessary to release the distal aponeurotic portion of the flexor retinaculum in endoscopic carpal tunnel release surgery?

Segmental carpal tunnel pressure was measured in 12 hands of 11 idiopathic carpal tunnel syndrome patients before and after two-portal endoscopic carpal tunnel release. We aimed to determine at which part of the carpal tunnel the median nerve could be compressed, and to evaluate whether carpal tunnel pressure could be reduced sufficiently at all segments of the carpal tunnel after the surgery. Pressure measurements were performed using a pressure guide wire. The site with the highest pressure corresponded to the area around the hamate hook; the pressure in the area distal to the flexor retinaculum could be pathogenically high (more than 30 mmHg) before the surgery. The two-portal endoscopic carpal tunnel release achieved sufficient pressure reduction in all segments of the carpal tunnel when the flexor retinaculum and the fibrous structure between the flexor retinaculum and the palmar aponeurosis were completely released.     

Assessment of outcome of carpal tunnel syndrome: a comparison of electrophysiological findings and a self-administered Boston questionnaire

The relationship between nerve conduction studies and the self-administered Boston Questionnaire that measures the severity of symptoms and functional status in carpal tunnel syndrome was assessed in 44 patients with idiopathic carpal tunnel syndrome. The patients were examined preoperatively and 3 and 6 months postoperatively. Although both the clinical outcome and electrophysiological findings improved significantly after surgery, we observed no correlation between improvements in nerve conduction and the questionnaire scores.     

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.     

Magnetic resonance imaging compared with electrodiagnostic studies in patients with suspected carpal tunnel syndrome: predicting symptoms, function, and surgical benefit at 1 year

OBJECT: The goal in this study of patients with clinical carpal tunnel syndrome (CTS) was to compare the usefulness of magnetic resonance (MR) imaging with that of electrodiagnostic studies (EDSs) for the following purposes: 1) prediction of 1-year outcomes and 2) identification of patients who are likely to benefit from surgical treatment. METHODS: The authors prospectively enrolled 120 patients with clinically suspected CTS. The participants were tested using standardized EDSs, MR imaging, and a battery of questionnaires, including the Carpal Tunnel Syndrome Assessment Questionnaire, a well-validated 5-point score of symptoms and function. The EDSs and MR images were each interpreted independently. Patients were reevaluated after 1 year. The decision to treat patients conservatively or by carpal tunnel release was made by the individual surgeon, who had access to the initial EDS but not MR imaging results. Univariate and multivariate analyses were used to determine associations between 1-year outcomes and baseline diagnostic tests. RESULTS: The authors recontacted 105 of 120 participants at 12 months. Of these, 30 patients had had surgery and 75 had not. Patients who had undergone surgery showed greater improvement at 1 year than those who had not had surgery. The length of the abnormal T2-weighted nerve signal on MR imaging and median-ulnar sensory latency difference were the strongest predictors of surgical benefit. There was a clear patient preference for the MR imaging over EDSs. CONCLUSIONS: The findings obtained with MR imaging of the carpal tunnel predict surgical benefit independently of nerve conduction studies.     

Results of treatment of severe carpal tunnel syndrome

A retrospective study was undertaken to determine the efficacy of carpal tunnel decompression in patients with advanced carpal tunnel syndrome. The criteria for inclusion in this study were unobtainable median sensory-evoked response and absent or prolonged median motor distal latency. Fifteen hands in 13 patients met these criteria. All patients had symptoms, including pain, weakness, or decreased sensation. Postoperative follow-up averaged 27 months. Symptomatic improvement was obtained in 14 of the 15 hands, and sensory-evoked response improved in 13 hands. Preoperative thenar atrophy was present in 10 of the 15 hands and was completely resolved in 2 of the 10 patients. These results indicate that carpal tunnel decompression is of benefit to patients with severe carpal tunnel syndrome. Long-standing symptoms, thenar atrophy, virtual anesthesia, and the absence of demonstrable sensory and motor-evoked responses are not contraindications to surgery.     

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.     

Carpal tunnel release in patients with diabetes result in poorer outcome in long-term study

Background

The aim of this prospective study was to compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes mellitus with those with idiopathic CTS.

Methods

The results of surgical decompression of CTS in 27 patients with diabetes mellitus were compared with 42 patients with idiopathic CTS. All patients underwent surgical release of transverse carpal ligament by the mini-incision of palm technique. Patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status was evaluated before and 6 months and 10 years after surgery.

Results

After surgical release, all the patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. Six months after surgery, there was a significant improvement of symptomatic and functional BQ scores compared with preoperative state in both groups. Ten years after surgery, there was statistical difference in preoperative and postoperative 10th year functional BQ score between DM (?) and DM (+) (p < 0.01). DM status affected statistically functional BQ score between preoperative and postoperative 10th year.

Conclusion

Diabetes mellitus was a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes had worse surgical outcome compared with patients with idiopathic CTS in long-term follow-up.     

Unusual causes of carpal tunnel syndrome: space occupying lesions

Space occupying lesions found at surgery caused or contributed to carpal tunnel syndrome in 23 of 779 patients operated for carpal tunnel syndrome from January 1999 to December 2008. The mean age of these 23 patients was 52.9 years, and in patients who had a local swelling or palpable mass, ultrasonography or magnetic resonance imaging (MRI) was done. All had open release of the transverse carpal ligament and lesions were removed. Histopathology showed tophaceous gout in 10 men, tenosynovitis in seven patients and tumors in eight. The tumors included ganglion cysts in two, lipoma in three and fibroma of the tendon sheath in one. The neurological symptoms subsided after surgery in all. In patients with gout, one had an infected wound and another had recurrence of symptoms 1 year after later. Carpal tunnel syndrome caused by a space occupying lesion is rare and more complicated than idiopathic carpal tunnel syndrome.