Carpal tunnel syndrome due to tophaceous gout

Tophaceous gout is a recognized cause of carpal tunnel syndrome. Of 2649 carpal tunnel releases, 15 hands in 13 patients were identified with tophaceous gout in the carpal tunnel. The incidence of tophaceous gout in the carpal tunnel was 0.6%. Twelve of 13 patients were male, and 8 of 10 patients with a history of gout developed carpal tunnel syndrome despite adequate medical treatment. Thus, consideration should be given for tophi as a cause of carpal tunnel syndrome, especially in older men despite medical treatment for gout.     

Case report. Initial manifestation of gout after carpal tunnel release.

A carpal tunnel release was performed on a patient with recurrent carpal tunnel syndrome and asymptomatic hyperuricaemia with no prior history of gouty arthritis. Intraoperatively, the patient was found to have tenosynovitis without crystals or tophaceous deposits in the carpal tunnel. Postoperatively, the patient developed an acutely inflamed hand, which responded dramatically to anti-gout medications. We report this patient as an initial attack of gout after a carpal tunnel release.     

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.     

Digital flexion contracture and severe carpal tunnel syndrome due to tophaceus infiltration of wrist flexor tendon: first manifestation of gout

The authors report an unusual case of flexor tenosynovitis, severe carpal tunnel syndrome, and triggering at the carpal tunnel as the first manifestation of gout. A 69-year-old man presented with digital flexion contracture and severe carpal tunnel syndrome of his right hand and was treated surgically. A flexor tenosynovectomy and a median nerve neurolysis were performed through an extended carpal tunnel approach. The sublimis and the profundus tendons were involved. Partial ruptures and multiple whitish lesions suggestive of tophacceous infiltration of the flexor tendons were seen. Macroscopically, the removed synovial tissue was involved by multiple whitish nodules that were milimetric in size and was suggestive of monosodium urate crystals deposits. By light microscopy examination, numerous nonnecrotizing granulomas of different sizes were observed that were compounded by large aggregations of acellular nonpolarized material, surrounded by epithelioid histiocytes, mononuclear cells, and foreign body multinucleated giant cells. Postoperatively, the patient recovered with resolution of the median nerve symptoms and a near-to-full range of motion of the affected digits.To the authors' knowledge, this patient is the first case report with flexor tendons tophacceous infiltration as the first clinical sign of gout. Gouty flexor tenosynovitis can occur in the absence of a long history of gout. A high index of suspicion is paramount to the initiation of proper management. Operative treatment of gouty flexor tenosynovitis is mandatory to debulk tophaceous deposits, improve tendon gliding, and decompress nerves. Routine uric acid determination could be helpful in the preoperative evaluation of patients with flexor tenosynovitis.     

Entrapment neuropathy caused by tophaceous gout

Entrapment neuropathy associated with gout is a rare occurrence. We report two cases of entrapment neuropathy of ulnar tunnel syndrome and carpal tunnel syndrome caused by gouty tophi. Problems related to its mechanism and treatment are discussed.     

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.     

Acute carpal tunnel syndrome caused by pseudogout.

Acute carpal tunnel syndrome caused by pseudogout occurred in a Chinese patient. The radiological findings mimicked those of synovial chondromatosis. Such radiological findings were very unusual. Diagnosis of such conditions may be difficult, since the clinical features may be confused with those of gout and infection. Surgical release is the treatment of choice.     

Medically managed gout precipitating acute carpal tunnel syndrome

Background

The most common compressive neuropathy affects the median nerve in the carpal tunnel; it is typically chronic and progressive. Acute carpal tunnel syndrome (ACTS), on the other hand, is a less frequently encountered surgical emergency that usually occurs in the setting of trauma, such as a displaced fracture of the distal radius or carpal dislocation. To our knowledge, there are only two cases of acute carpal tunnel secondary to gout reported in the literature, with both being outside of the USA and the last case being over 20 years ago. We reviewed the literature describing acute carpal tunnel syndrome (ACTS) caused by gout and present a recent case of atraumatic ACTS caused, in part, by a tophaceous gouty mass.

Methods

Review of the literature consisted of a PubMed search of all articles in the English language using the following keywords: “Acute Carpal Tunnel Syndrome” and “Tophaceous Gout” and “Gout.”

Results

We present the youngest reported case of atraumatic ACTS caused by tophaceous gout and the only reported case with a documented history of gout being actively medically managed with a uric acid lowering agent. This was successfully treated with an emergent extended carpal tunnel release, a complete flexor synovectomy, and excision of a gouty mass adhered to the carpal tunnel floor.

Conclusions

Atraumatic ACTS secondary to gout is rare and has never been reported in a patient already being managed with uric acid lowering agents. Such a presentation requires rapid surgical exploration with release of the carpal tunnel, debridement of all gouty tissue, and increasingly aggressive adjuvant medical therapy.     

痛风石致腕管综合征的手术治疗

目的 探讨痛风石导致腕管综合征的临床特点及手术治疗效果.方法 回顾性分析2017年10月至2019年12月于复旦大学附属华山医院手外科接受手术治疗的16例(17侧)痛风石致腕管综合征病人的临床资料,痛风病程(7.68±5.48)年,腕管综合征病程(5.22±2.24)个月.术中7侧可见正中神经局部压痕,9侧痛风石广泛包...     

Two cases of endoscopic management of carpal tunnel syndrome in macrodactyly patients.

Some cases of carpal tunnel syndrome in macrodactyly patients have been reported. We performed endoscopic carpal canal release on two unilateral macrodactyly patients suffering from bilateral carpal tunnel syndrome. We measured carpal canal pressure before performing endoscopic surgery using the Universal Subcutaneous Endoscope system to confirm median nerve compression. We diagnosed median nerve compression in each patient due to the high preoperative carpal canal pressure. Carpal canal pressure immediately decreased to within normal range following release of both the flexor retinaculum and the distal holdfast fibres of the flexor retinaculum. One patient recovered to within normal in terms of sensory disturbances and abductor pollicis brevis muscle strength. The other patient showed improvement in terms of sensory disturbance, however, muscle power did not recover because this patient had suffered from carpal tunnel syndrome for ten years. Endoscopic carpal canal release and decompression surgery was effective for carpal tunnel syndrome in both macrodactyly patients.     

Proximal ulnar nerve compression secondary to tophaceous gout

Although gout is a recognised but rare cause of carpal tunnel syndrome, compression of the ulnar nerve by tophaceous gout is rare. We describe a case of proximal ulnar nerve compression due to tophaceous gout in an 87-year-old man. Surgical decompression, with excision of the lesion and a section of the ulnar belly of Flexor Carpi Ulnaris produced symptomatic relief. This case illustrates that in the differential diagnosis of ulnar nerve palsy, tophaceous gout should be considered in those patients with known gout.     

Muscle atrophy at diagnosis of carpal and cubital tunnel syndrome

PURPOSE: This study was designed to test the hypothesis that patients with an initial diagnosis of cubital tunnel syndrome are more likely to present with muscle atrophy than patients with an initial diagnosis of carpal tunnel syndrome. METHODS: A list of patients presenting to the office of a single hand surgeon from January 2000 to June 2005 with an initial diagnosis of isolated, idiopathic carpal tunnel syndrome or cubital tunnel syndrome was generated from billing records. The medical records of 58 patients with cubital tunnel syndrome and 370 patients with carpal tunnel syndrome were reviewed for age, gender, diabetes, and presence of atrophy. RESULTS: Twenty-three of 58 patients with an initial diagnosis of cubital tunnel syndrome had atrophy compared with only 62 out 370 patients with an initial diagnosis of carpal tunnel syndrome. Multiple logistic regression revealed that age (odds ratio, 1.06; 95% CI, 1.04-1.08) and diagnosis (cubital tunnel patients were more likely than carpal tunnel patients to present with atrophy; odds ratio, 4.5; 95% CI, 2.7-8.6) were factors significantly associated with atrophy at presentation. CONCLUSIONS: Patients with carpal tunnel syndrome present earlier in the course of their disease than patients with cubital tunnel syndrome. Patients with cubital tunnel syndrome are more likely to present with muscle atrophy, reflecting advanced nerve damage that may not respond to surgery.     

腕管综合征复发7例分析

目的 总结7例小切口手术治疗腕管综合征复发病例的诊治过程,为临床提供治疗经验.方法 2012年1月至2019年12月,对已在外院经临床和电生理确诊为腕管综合征且行小切口手术治疗后复发的7例病人进行二次常规手术切口治疗.术中探查发现7例腕管内均有白色粉末状物沉积,给予腕管内病灶清除及彻底松解正中神经.根据顾玉东推荐的腕管...     

Acute carpal tunnel syndrome caused by pigmented villonodular synovitis of the wrist

An 89-year-old woman developed an acute carpal tunnel syndrome secondary to hemarthrosis associated with pigmented villonodular synovitis of the wrist. Pigmented villonodular synovitis is rare in a patient of this age and is an unusual cause of carpal tunnel syndrome.     

The relationship of the double crush to carpal tunnel syndrome (an analysis of 1,000 cases of carpal tunnel syndrome)

In this series of 1,000 cases of carpal tunnel syndrome (888 patients) there is a statistically significant incidence of bilaterality in patients with cervical arthritis. There is also a statistically significant increase in the incidence of diabetes mellitus over the general population. These findings lend further support to Upton's Double Crush hypothesis. Further, the double crush syndrome predisposes to bilateral carpal tunnel syndrome and may be an important prognostic factor. It may also be an explanation for some of the failures following carpal tunnel surgery and lead surgeons to look for other associated systemic diseases or mechanical blocks, when attempting to alleviate recalcitrant symptoms.     

Histo-mechanical aspects of carpal tunnel syndrome

Carpal tunnel syndrome is a result of median nerve compression within the carpal canal. Factors associated with the appearance of carpal tunnel syndrome can be related to the bony architecture of the carpal canal, to its contents and to systemic disease. The purpose of this work is to see if changes in the elasticity of the transverse carpal ligament may cause carpal tunnel syndrome.     

Carpal tunnel syndrome: relationship between clinical and patient-oriented assessment

Clinical diagnosis of carpal tunnel syndrome usually is easy and sensitive, but frequently, it is based on history and referred symptoms when no motor or sensory deficits are observed during examination. In patients with carpal tunnel syndrome, a dissociation between the severity of the disease reported by the patient and the deficits clinically evaluated by the physician often are observed. The Italian Carpal Tunnel Syndrome Study Group did a multicenter study on 740 patients (1123 hands) with carpal tunnel syndrome to assess the aspects of dissociation between the patient's and the physician's quantification of the disease severity and the ability of the patients with carpal tunnel syndrome to do daily activities. Validated patient-oriented parameters assessing symptoms and hand functional status were used. The relationship between the physician's and the patient's measurements is strong with a linear significant correlation when analyzing the functional status of the hand but not so clear and simple when analyzing the symptoms. Patients with mild-to-moderate carpal tunnel syndrome seemed to function well, although severe symptoms may be reported by the patient; however, when nerve impairment becomes severe, the patient's hand function is extremely impaired although symptoms may be milder. The data show that the patient's point of view is reliable. Carpal tunnel syndrome seems to be an ideal model to evaluate the importance of patient-oriented measurements.     

The familial incidence of carpal tunnel syndrome in patients with unilateral and bilateral disease

The controversy has been considerable regarding the incidence of familial carpal tunnel syndrome. Of particular interest is the relationship between bilateral disease and familial incidence. In this study, we compare the incidence of familial carpal tunnel syndrome in patients with the syndrome in one, both, or neither hands. We report a significantly greater incidence of familial carpal tunnel syndrome in those patients with bilateral disease than in a similar population of patients with either unilateral disease or no carpal tunnel syndrome. These results may imply inheritability of variations in the size of the tunnel or its contents, which would manifest themselves bilaterally and may cause a predisposition for developing the syndrome. Being aware of the propensity for bilateral disease may improve our ability to prevent and treat the disease.     

Endoscopic carpal tunnel release in patients receiving long-term hemodialysis

This study evaluated the clinical results of endoscopic carpal tunnel release in carpal tunnel syndrome caused by long-term hemodialysis and compared the results with that of idiopathic carpal tunnel syndrome. Operations were done in 32 patients (60 hands) with idiopathic carpal tunnel syndrome and in eight patients (15 hands) with carpal tunnel syndrome resulting from long-term hemodialysis. There was no significant difference in findings of preoperative evaluations and postoperative clinical results between the two groups, except for a difference with the patient satisfaction score with surgery on a visual analogue scale. The mean satisfaction score was 9.0 at 6 months, 9.3 at 1 year, and 9.5 at the 2-year followup in the group of patients with idiopathic carpal tunnel syndrome. However, in the group of patients with carpal tunnel syndrome resulting from long-term hemodialysis, the mean satisfaction score was 8.5 at 6 months, 8.2 at 1 year, and 6.5 at the 2-year followup. The score began to decrease at an average of 17.2 months after surgery. Long-term hemodialysis related carpal tunnel syndrome showed satisfactory short-term clinical results until approximately 1.5 years after the operation. After that time, the symptoms tended to deteriorate in 50% of the patients who received hemodialysis continuously.     

手部痛风的手术治疗

目的 探讨手部痛风的手术疗效及诊治经验。方法 对16例手部痛风伴有结石、关节肌腱粘连及腕管综合征的患者，采用单纯痛风石切除5例，痛风石切除同时行肌腱粘连松解及部分指浅屈肌腱切除5例，痛风石切除、腕管切开减压正中神经或指神经松解6例。术前、术后1周内服用痛风利仙50mg／次，每日2次，西乐葆0．2g/次，每日1次。结果 术后全部病例均切除了痛风结石，同时纠正了手指的外形畸形，手指麻木症状好转，皮肤无坏死，伤口均Ⅰ期愈合。术后随访5个月～5年，未见痛风石复发，手指外形及功能满意。结论 手术治疗对痛风晚期进行痛风石清除有效，同时也可纠正畸形及外形，改善手功能。