Evaluation of hand function and symptom severity among patients after endoscopic carpal tunnel release]

The aim of the study was to evaluate function of hand and symptom severity after endoscopic carpal tunnel release. The examined material in this study comprises 45 patients (56) hands operated with single-portal endoscopic method. In order to evaluation outcomes of treatment Carpal Tunnel Syndrome Symptom Severity Scale (CTS SSS), Carpal Tunnel Syndrome Functional Status Scale (CTS FSS) and clinical examinations outcomes were used. Average results of preoperative questionnaires were equaled respectively: CTS SSS--2.9 and CTS FSS--2.8. Average results of postoperative questionnaires were equaled respectively: CTS SSS--1.5 and CTS FSS--1.7. Statistical analysis has shown significantly better results of CTS SSS and CTS FSS questionnaires, among patients with positive Tinel's Test and without thenar atrophy found before operation. Results of research based on questionnaires and clinical examinations, proved fast return of function of hand and decrease symptoms severity after endoscopic carpal tunnel release.     

腕管综合征治疗研究进展

目的对腕管综合征(carpal tunnel syndrome,CTS)的治疗研究现状作一综述。方法查阅近年来国内外CTS治疗的相关文献,进行分析总结。结果腕夹板、类固醇适用于轻、中度CTS患者,近期效果显著;治疗后复发的CTS患者需采取手术治疗。主要术式为腕管松解术,包括腕管切开松解减压术(传统型和小切口型)、内镜下腕管松解减压术等。结论 CTS的最佳治疗方法尚无定论,部分学者推荐首选手术治疗。     

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.     

Carpal tunnel syndrome: a major complication in long-term hemodialysis patients

One hundred and forty-five patients on hemodialysis for periods of 1 month to 16 years were examined clinically for carpal tunnel syndrome (CTS). Typical symptoms and clinical manifestations of symptomatic CTS, either unilaterally or in both hands, were detected in 21 of these patients (15%). In contrast to the classic form of CTS, hemodialysis CTS in our patients was frequently accompanied by Raynaud's phenomenon of those digits supplied by the median nerve. A highly significant correlation was established between the incidence of CTS and the duration of dialysis (p less than 0.001). The association of CTS with analgesic nephropathy was significantly higher (52%) than with other kidney diseases (p less than 0.034). Immediate relief of pain was achieved after carpal tunnel release (11 releases) in 8 of the 21 patients. Sensory and motor function was gradually, but often only partially, restored. Unoperated CTS progressed to loss of sensory and motor function within 1 to 4 years after the onset of symptoms. CTS should be considered a major late complication in patients on chronic hemodialysis.     

Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder and Hand questionnaire in carpal tunnel surgery

PURPOSE: Symptom resolution and functional improvement are the 2 primary reasons for patients to seek treatment for carpal tunnel syndrome (CTS). This study aimed to measure the responsiveness of the Michigan Hand Outcomes Questionnaire (MHQ) and Disabilities of the Arm, Shoulder and Hand (DASH) when evaluating outcomes after carpal tunnel surgery. METHODS: Fifty patients prospectively completed the MHQ and the DASH before and 6 months after open carpal tunnel release. Data were analyzed using paired t tests and responsiveness to clinical change was calculated by using standardized response means (SRMs). RESULTS: All domains of the MHQ significantly improved after carpal tunnel release: the pain scale had a large SRM of 0.9 and the function scale showed medium responsiveness of 0.6. The combined function/symptom scale of the DASH significantly improved after surgery; the SRM revealed a medium effect of 0.7. CONCLUSIONS: The MHQ and the DASH are both responsive in measuring outcomes of carpal tunnel surgery. The MHQ has subscales that can measure symptom and function improvement independently. The MHQ and the DASH can be used for outcomes research related to carpal tunnel surgery with the advantage of also being useful for assessing and comparing outcomes for various other hand disorders.     

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.     

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.     

Diagnostic utility of waveform analysis of compound muscle action potentials for carpal tunnel syndrome

PURPOSE: To determine the diagnostic utility of waveform analysis of compound muscle action potentials (CMAP) for carpal tunnel syndrome (CTS). METHODS: A total of 131 hands in 71 patients diagnosed with CTS (grouped according to severity) and 80 hands in 44 normal subjects were evaluated using nerve conduction test through the carpal tunnel combined with waveform analysis of CMAP. RESULTS: Compared to normal subjects, the sensory nerve conduction velocity and mean frequency of the CMAP waveform were significantly reduced in patients with CTS. Compared with distal motor latency and sensory nerve conduction velocity, the mean frequency of the CMAP decreased significantly with increasing clinical severity. CONCLUSION: This study suggests that waveform analysis of CMAP is of diagnostic value in CTS, and is also of value in objective evaluation of postoperative recovery of carpal median nerve dysfunction.     

Carpal tunnel syndrome with severe sensory deficit: endoscopic release in 18 cases

Carpal tunnel syndrome (CTS) with severe sensory deficit was treated with endoscopic carpal tunnel release in 18 hands of 16 consecutive patients (median age 72 (28-92) years). In all hands, preoperative 2-point discrimination (2-PD) exceeded 15 mm in the radial and ulnar sides of the pulps of at least 2 of the 3 radial digits. All patients underwent an independent evaluation and answered a questionnaire concerning 11 activities of daily living (ADL) preoperatively and 6 months postoperatively. Complete resolution or improvement in daytime numbness and tingling was reported in 12 of 17 hands, of night symptoms in 12 of 16 hands, and of pain in 10 of 11 hands. The median ADL score improved from 3.1 to 1.4 (on a 1- to 5-point scale). 13 of the 16 patients were satisfied with the outcome. Two-PD had normalized in 14 hands and improved in 2. The results indicate that endoscopic carpal tunnel release is effective in improving symptoms and function in patients with CTS and severe sensory deficit, and that the prognosis for sensory recovery is good.     

Epidemiologic Associations of Carpal Tunnel Syndrome and Sleep Position: Is There a Case for Causation?

INTRODUCTION: Carpal tunnel syndrome (CTS) is thought to be due to compression of the median nerve in the carpal tunnel. It is known that carpal tunnel pressures are elevated in wrist postures of flexion and extension and in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling, and numbness. These classic symptoms stimulated our interest in the relationship of sleep to the development of CTS. METHOD: We reviewed the literature surrounding the epidemiology of CTS and the literature regarding sleep disturbances. Through careful distillation of these studies and a process of reasoning, we have developed a hypothesis for a causal mechanism of CTS. RESULTS: Epidemiologically, it has been shown that CTS is associated with age, gender, increased body mass index (BMI), diabetes, pregnancy, and is more common in some populations. The same associations noted above for CTS are strongly associated with sleep disturbances. Sleep disturbances due to age, gender, BMI, pregnancy, and population variations are all associated with sleeping in the lateral position supporting the hypothesis that a common causative mechanism of CTS is sleeping in a lateral position. DISCUSSION: We believe that the epidemiologic associations with CTS act through a common causative mechanism, increased sleeping in the lateral position which puts the wrist at increased risk of flexion or extension, compressing the median nerve in the carpal tunnel. This hypothesis is simple and explains the connection between a previously unconnected group of epidemiologic associations. This realization has real clinical significance in that it focuses our attention on the early disorder when it is completely reversible. It clarifies previously confused clinical circumstances, creates research questions that can be tested, and it invites us to change our clinical perspective in this most common form of nerve compression.     

Carpal tunnel syndrome with severe sensory deficit: Endoscopic release in 18 cases

Carpal tunnel syndrome (CTS) with severe sensory deficit was treated with endoscopic carpal tunnel release in 18 hands of 16 consecutive patients (median age 72 (28-92) years). In all hands, preoperative 2-point discrimination (2-PD) exceeded 15 mm in the radial and ulnar sides of the pulps of at least 2 of the 3 radial digits. All patients underwent an independent evaluation and answered a questionnaire concerning 11 activities of daily living (ADL) preoperatively and 6 months postoperatively. Complete resolution or improvement in daytime numbness and tingling was reported in 12 of 17 hands, of night symptoms in 12 of 16 hands, and of pain in 10 of 11 hands. The median ADL score improved from 3.1 to 1.4 (on a 1- to 5-point scale). 13 of the 16 patients were satisfied with the outcome. Two-PD had normalized in 14 hands and improved in 2. The results indicate that endoscopic carpal tunnel release is effective in improving symptoms and function in patients with CTS and severe sensory deficit, and that the prognosis for sensory recovery is good.     

Carpal tunnel syndrome with severe sensory deficit: Endoscopic release in 18 cases

Carpal tunnel syndrome (CTS) with severe sensory deficit was treated with endoscopic carpal tunnel release in 18 hands of 16 consecutive patients (median age 72 (28-92) years). In all hands, preoperative 2-point discrimination (2-PD) exceeded 15 mm in the radial and ulnar sides of the pulps of at least 2 of the 3 radial digits. All patients underwent an independent evaluation and answered a questionnaire concerning 11 activities of daily living (ADL) preoperatively and 6 months postoperatively. Complete resolution or improvement in daytime numbness and tingling was reported in 12 of 17 hands, of night symptoms in 12 of 16 hands, and of pain in 10 of 11 hands. The median ADL score improved from 3.1 to 1.4 (on a 1- to 5-point scale). 13 of the 16 patients were satisfied with the outcome. Two-PD had normalized in 14 hands and improved in 2. The results indicate that endoscopic carpal tunnel release is effective in improving symptoms and function in patients with CTS and severe sensory deficit, and that the prognosis for sensory recovery is good.     

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.     

Development and validation of diagnostic criteria for carpal tunnel syndrome

PURPOSE: To develop clinical diagnostic criteria for carpal tunnel syndrome (CTS) that modeled the clinical diagnostic practices of experts. METHODS: Fifty-seven clinical findings associated with CTS had been ranked previously in order of diagnostic importance using Delphi as a method of establishing consensus among a panel of expert clinicians. The 8 most highly ranked criteria then were placed into all possible combinations to create 256 unique case histories. Two new panels of experts rated these case histories. One panel made a binary evaluation as to whether the case history did or did not represent CTS. This allowed the development of a logistic regression model that had the probability of carpal tunnel syndrome as the dependent variable and the weighted diagnostic criteria as the independent variables. This model then was validated against the judgments of the second panel of clinicians who estimated the probability of CTS for each of the same case histories. RESULTS: The correlation between the probability of CTS predicted by the model and the panel of clinicians was 0.71. CONCLUSIONS: The most important clinical diagnostic criteria for CTS as identified from a larger pool of potential diagnostic items through a consensus approach using Delphi were weighted and found to correlate well with the judgments of a new panel of clinicians. By improving the consistency of the diagnosis of CTS these criteria should lead to more effective treatment and a better understanding of the effect of workplace exposures in the development of this condition. A methodology that emphasizes a rigorous approach to item generation and item reduction through expert consensus, followed by validation, may represent a template for establishing consensus among experts on other controversial clinical issues. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic, Level I.     

Which Outcome Measure is the Best? Evaluating Responsiveness of the Disabilities of the Arm,Shoulder, and Hand Questionnaire,the Michigan Hand Questionnaire and the Patient-Specific Functional Scale Following Hand and Wrist Surgery

The purpose of this study was to determine and compare the responsiveness of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Michigan Hand Questionnaire (MHQ), and the Patient-Specific Functional Scale (PSFS) in patients with carpal tunnel syndrome, wrist pain, finger contracture, or tumor. Eighty-one subjects prospectively completed each questionnaire shortly before and 3 and 6 months after surgery. Data were analyzed using one-way analysis of variance and Newman–Keuls multiple comparison tests. Responsiveness to clinical change was calculated using standardized response means. The DASH was responsive for those with carpal tunnel syndrome (0.77), wrist pain (0.61), and tumor (0.55); the MHQ was responsive for those with carpal tunnel syndrome (1.04), wrist pain (0.87), and finger contracture (0.62); and the PSFS was responsive for those with carpal tunnel syndrome (0.65) and finger contracture (0.64). The interval during which the highest responsiveness occurred for the carpal tunnel, wrist pain, and finger contracture groups was the preoperative to 6-month period. The tumor group experienced the highest responsiveness during the preoperative to 3-month period. Our results indicate that one or more of the instruments evaluated are suitable for outcomes research related to surgery to treat carpal tunnel syndrome, wrist pain, finger contracture, and tumor.     

Carpal tunnel syndrome. Anatomical and clinical investigation

The anatomy of the carpal tunnel was studied by postmortem dissection of both wrists in ten adults with normal wrists. Preoperative clinical and EMG examinations were performed on 28 wrists in 23 patients suffering from carpal tunnel syndrome. Anatomical and histological studies were made in connection with operation, and postoperatively the condition was followed clinically and by EMG. Numbness, tingling, and pain of the hands were markedly relieved during 2 months of follow-up, whereas clumsiness and weakness showed no significant change. preoperatively, EMG showed sensory abnormalities in 96% of cases and motoric abnormalities in 82%. The diagnostic accuracy of EMG was good, in particular as regards the sensory aspect. The return to normal of EMg was slow. Pathoanatomical examination showed a normal tendon sheath and transverse carpal ligament in 52%, while rheuma was found in the specimens of 12%, fibrosis of the tendon sheath in 36%, and fibrosis of the transverse carpal ligament in 32%. No correlation was observed between the shape of the osseous carpal tunnel and the degree of clinical symptoms.     

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.     

掌部小切口减压治疗腕管综合征

目的:介绍掌部小切口横断腕横韧带治疗腕管综合征的方法,并评价其疗效及安全性。方法:自2006年1月至2007年9月,采用掌部纵形小切口,切断腕横韧带治疗腕管综合征15例(18侧),男2例,女13例;年龄34～69岁,平均48岁;单侧12例,双侧3例;病程8～26个月,平均18个月。主要临床表现为:桡侧3个半指麻木或疼痛,腕部疼痛,并向前臂放射,夜间麻醒史,大鱼际肌肉萎缩,Tinel征阳性,Phalen征阳性。电生理检查均有正中神经感觉神经传导速度(SCV)减慢、感觉神经动作电位(SNAP)波幅下降或缺失,严重者拇短展肌可有自发电位。术后随访时采用GSS评分(Global symptom score),分别从疼痛、麻木感、感觉异常、肌力减退和夜醒等5个方面进行评价。结果:术后所有患者伤口均甲级愈合,无并发症发生。15例患者均获随访,时间20～28个月,平均24个月。除1例患者未完全缓解外,其余患者症状消失,拇短展肌肌力增强,GSS评分较术前有明显改善(P<0.05)。结论:小切口减压治疗腕管综合征具有安全性高、手术时间短、创伤小、瘢痕小等优点,直视下切断腕横韧带,可彻底松解正中神经,是安全、有效的手术入路。     

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.     

Outcomes of Mini-Open Carpal Tunnel Release in Patients With Unrecordable Preoperative Nerve Conduction Potentials at a Minimum of 5 Years

Background: The aim of this study is to assess the outcomes of carpal tunnel release (CTR) in a cohort of patients with preoperatively unrecordable median nerve sensory and motor potentials in comparison with historical controls at minimum 5-year follow-up. Methods: We retrospectively identified 1297 patients who underwent CTR at a tertiary care referral center from July 2008 to June 2013. After exclusion criteria and review of available preoperative nerve conduction studies, 24 patients who underwent CTR with preoperative unrecordable sensory and motor nerve potentials were identified. Fifteen living, mentally capable patients were contacted by telephone for follow-up. Our primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Secondary outcome measures included Disabilities of the Arm, Shoulder, and Hand (DASH) score, pain on a 0 to 10 Likert scale, and satisfaction on a 0 to 10 Likert scale. Results: Our response rate was 80% (12 out of 15) of eligible patients. Mean follow-up was 6.9 years in our study (range, 5.4-9.5 years). The mean BCTQ symptom score was 1.4, and the mean BCTQ functional score was 1.8. Mean DASH score was 15.2. On average, patient-reported pain was 0.3 and satisfaction was 8.3. No difference was found in outcomes of CTR in patients with end-stage carpal tunnel syndrome compared with historical means. Conclusions: Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after CTR compared with the general population. Unrecordable nerve potentials are not a contraindication for CTR.