The operative treatment of carpal tunnel syndrome and its relevance to endoscopic release

The results of open carpal tunnel release using a short incision (2.5 cm) have been compared with those following a long incision (4.5 cm) in a prospective randomized study. Eighty patients were operated upon with a follow-up rate of 100%. The variables examined included grip strength, key and pulp pinch strength, sensory function and scar tenderness. Subjective variables such as tingling, numbness and night symptoms were specifically enquired into, and time for return to work was noted. The examinations took place pre-operatively, as well as one, two, three and six weeks post-operatively. Median time for return to work was 21 days for the short incision group and 18 days for the long incision group. The long incision resulted in a significant 10% loss of strength only at week three, otherwise no significant difference was found between the results of the two groups. Received: 30 March 1998 / Accepted: 1 December 1998     

Pathology of the flexor tendon sheath in the spontaneous carpal tunnel syndrome

The histological features of the flexor tendon sheath in the spontaneous carpal tunnel syndrome were studied. The main differences between our findings and previous studies were twofold. Firstly a striking absence of inflammation in our material and secondly the diversity of the pathological changes encountered--alterations in the connective tissue especially the collagen; proliferation with thickening of the tissues of the tendon sheath; fibrosis; amyloid deposition; oedema; vascular lesions including thickening of vessels walls, intimal hyperplasia, and thrombosis; and a foreign body giant cell reaction. Although the lesions described here may not be significant in every case in which they are encountered, they do appear to support the view that pressure in the carpal tunnel and ischaemia are the important factors in a majority of cases of the spontaneous carpal tunnel syndrome.     

Mycobacterium kansaii flexor tenosynovitis presenting as carpal tunnel syndrome

We present a case in which Mycobacterium kansasii flexor tenosynovitis caused the development of carpal tunnel syndrome. The diagnosis was made from synovial tissue specimens taken at the time of operation.     

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."     

Nonoperative carpal tunnel syndrome treatment

Many factors influence the development of CTS; therefore, nonoperative treatment should not be limited to only one intervention. Nonoperative treatment is most effective in the early stages, prior to irreparable damage to the nerve. Early intervention combined with a comprehensive treatment plan can help improve effectiveness of treatment during this phase. We do not endorse any one particular conservative treatment/program as the solution for CTS, but our purpose is to explore potential options. Further study is needed to determine the most beneficial and cost-effective treatments.     

The possible role of vascular congestion in carpal tunnel syndrome

A study of interstitial pressures within the carpal tunnel using a slit catheter found that, in some patients, an initial rise in pressure is recorded when the wrist is passively extended and this continues to rise to a plateau if the position is maintained. A rise above a critical pressure brought about by congestion would explain the clinical picture of predominantly nocturnal symptoms and no electro-physiological evidence with the wrist in a neutral (resting) position. The results also bring into doubt published results of the pressure within the carpal tunnel with the wrist flexed or extended, since the pressure can be changed at will, depending on the flexion or extension force used.     

Elongated muscle belly of the flexor digitorum superficial causing carpal tunnel syndrome

Background

Carpal tunnel syndrome (CTS) is by far the most common entrapment neuropathy (Adams et al. Am J Ind Med 25:527–536, 1994; Cheadle et al. Am J Public Health 84:190–196, 1994; Stevens et al. Neurology 38:134–138, 1988). A combination of described symptoms, clinical findings and electrophysiological testing is used to confirm the diagnosis. Several studies have suggested that in patients with a clinical diagnosis of CTS, the accuracy of nerve sonography is similar to that for electromyography (Chen et al. BMC Med Imaging 11:22, 2011; Guan et al. Neurol Res 33:970–953, 2011; Kele et al. Neurology 61:389–391, 2003; Tai et al. Ultrasound Med Biol 38:1121–1128, 2012). In special cases though, the nerve sonography can reveal the cause of the median entrapment neuropathy (Fumière et al. JBR-BTR 85:1–3, 2002; Kele et al. J Neurosurg 97:471–473, 2002; Kele et al. Neurology 61:389–391, 2003; Zamora et al. J Clin Ultrasound 39:44–47, 2011).

Methods

A 43-year-old farmer was admitted to our department with 1 year of intermittent pain in the left hand and numbness of the thumb, index and middle finger. The pain and the numbness could be reproduced by extension of the wrist and fingers. The electrophysiological testing revealed signs of an entrapment median neuropathy in carpal tunnel.

Results

The high-resolution sonography (18 MHz) revealed signs of entrapment neuropathy with increased cross-sectional area, disturbed echostructure of the nerve and pathological wrist-to-forearm ratio, confirming the results from a similar study (Kele et al. Neurology 61:389–391, 2003). In addition, an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel could be identified. During the extension of the wrist and fingers, a greater protrusion of the muscle belly could be demonstrated causing compression of the median nerve.

Conclusions

We present a video case report of the sonographic findings of a patient diagnosed with carpal tunnel syndrome due to an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel. Our case highlights the importance of nerve sonography in the differential diagnosis of the cause of a carpal tunnel syndrome. With the aid of ultrasonography, it is possible to obtain very important information concerning different aspects of this case. First, in showing the presence of the elongated muscle belly of the flexor digitorum superficialis, the cause of the symptoms could be explained. Second, it was possible through the ultrasound study to explain the atypical clinical appearance in this case, demonstrating the compression neuropathy only after extension of the wrist and fingers. There have been no previous reports in which authors described an elongated muscle belly as cause of a CTS. Third, and perhaps most important, ultrasonography had a direct influence on our selection of therapeutical strategy and approach. As a result, we recommended in this patient a surgical therapy to completely solve the problem, but the patient declined this option and preferred a conservative therapy with a hand orthosis to prevent wrist extension. In conclusion we recommend ultrasonography as a very useful method in the diagnostic evaluation of carpal tunnel syndrome. We have clearly demonstrated that ultrasonography can be used to discover the cause of median nerve compression, especially in cases with an atypical clinical presentation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11552-012-9435-z) contains supplementary material, which is available to authorized users.     

腕管综合征的显微外科治疗

[目的]报道腕管综合征的显微外科治疗效果.[方法]术中在显微镜下神经外膜松解,彻底松解腕管部分的正中神经,并在神经周围放置醋酸泼尼松龙,术后观察其疗效.[结果]术后随访1个月～2年,147例症状完全消失,15例大部分症状缓解,拇、食、中指术后指腹两点辨别觉恢复正常,大鱼际萎缩者,肌萎缩明显改善,拇指对掌功能恢复.无1例产生腕掌部瘢痕痛及正中神经、掌浅弓、正中神经返支损伤等并发症.[结论]显微外科神经松解是治疗腕管综合征的有效方法.     

Idiopathic carpal tunnel syndrome: histologic study of flexor tendon synovium

The histologic lesions in flexor tendon synovium of 21 patients seen initially with idiopathic carpal tunnel syndrome have been studied. The findings were similar in all biopsy specimens and were typical of a connective tissue undergoing degeneration under repeated mechanical stresses.     

腕管综合征治疗进展

腕管综合征是腕管内正中神经受压而产生的一系列手部症状和功能障碍,其发病率近年来逐渐上升。对轻度或中度的腕管综合征患者,可考虑保守治疗,目前认为疗效较明确的有支具固定和皮质类固醇激素局部注射。对严重或经保守治疗无效的腕管综合征患者,可选用手术治疗,肌肉萎缩是手术治疗绝对指征,腕管松解减压术是最常用手术,包括传统的腕管切开松解减压术和内镜下腕管松解减压术,两种手术的长期疗效和并发症率无显著差别。手术治疗的成功率明显高于保守治疗。     

The role of wrist anthropometric measurement in idiopathic carpal tunnel syndrome

Anthropometric wrist measurement ratios were examined for an association with idiopathic carpal tunnel syndrome (CTS). Wrist measurements were recorded in 67 patients with CTS and in a matched control group of 67 healthy volunteers. The Wrist Ratio (WR) (wrist anterior to posterior dimension/wrist medial-lateral dimension) and the Wrist Palm Ratio (wrist anterior to posterior dimension/palm length) were calculated for each case. We found that a WR of > or =0.70 and a Wrist Palm Ratio of >0.342 were significantly associated with idiopathic CTS.     

Histopathology of the flexor tendon sheaths and its relevance in idiopathic carpal tunnel syndrome

Compression of the median nerve in the carpal tunnel can be produced by a variety of factors, including fractures, metabolic disturbances, rheumatoid arthritis or anatomical anomalies. When it is not possible to identify a specific cause, the term ”idiopathic carpal tunnel syndrome” is used. Although this disease is very common, its pathophysiology is still unclear. In the past, the presence of a chronic non-specific tenosynovitis around the flexor tendons was postulated but several investigations failed to show any inflammatory reaction in the carpal synovium. In this study, the histology of the flexor tendon sheaths in a group of 50 patients surgically treated for idiopathic carpal tunnel syndrome (ICTS) have been investigated both from the qualitative (histopathology) and quantitative (micrometric evaluation) points of view. Lack of acute or chronic inflammatory cells, connective disorganization, and vascular modifications are the main histological findings which are present in all the specimens, regardless of the patient’s age, the duration of the sensory symptomatology or the severity of the neurological lesion on EMG exam. The carpal synovium in these patients appeared thickened when compared to the specimens obtained from the control group. However, on micrometric evaluation a relationship between synovial thickness and severity of the symptomatology or of the EMG data was not observed. The carpal synovium in ICTS has a consistent histological appearance and is increased in thickness when compared with normal specimens. Received: 18 September 1998 / Accepted: 14 April 1999     

The carpal tunnel syndrome in children

Introduction

Carpal tunnel syndrome (CTS) in children represents a complex challenge for the hand surgeon because of its rarity, poor patient cooperation, frequently associated malformation syndromes and mental retard, atypical symptoms and nuanced and poor sensitivity of instrumental tests. The most frequently associated causes with the CTS in children are rare congenital malformations and diseases, requiring an overall assessment of the young patient and a high degree of suspicion for the potentially associated canalicular syndrome. On the other hand, the associated syndromes may be the main ally for a diagnosis that starts from the knowledge of the literature and the surgeon's suspicion by observing the child wailing. Early diagnosis and decompression treatment is mandatory.

Materials and methods

The authors report a case series of 26 children and analyze the etiology and diagnostic algorithms. Patient assessment was based on complete clinical examination and medical history collection of these young patients with the involvement of the family and educators.

Results

In all 26 patients treated, along an average period of 23 months (minimum 12, maximum 30), no signs of recurrence or persistence of median nerve disturbances were recorded.

Conclusions

In conclusion, we believe that anamnesis, a careful physical examination and analysis of instrumental examinations, should be accompanied by a thorough knowledge of rare diseases in the context of congenital malformations. The carpal tunnel syndrome, while well known and treated by each orthopedic surgeon, reveals a mysterious aspect in the context of the "fabulous" world of childhood illnesses, even more difficult than rare congenital diseases.

     

腕管综合征与肘管综合征诊治中的有关问题

腕管与肘管综合征是手外科临床中最常见的二类周围神经卡压征,如何规范它们的诊治标准是进一步开展临床研究的必要条件,为此笔者将近期有关资料进行综合,并提出相关的诊治标准,供全国同道讨论、修改与参考.