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carpal_tunnel_syndrome

Carpal tunnel syndrome (CTS)

Carpal tunnel syndrome occurs when the median nerve, becomes pressed or squeezed at the wrist.

The most common compressive neuropathy affects the median nerve in the carpal tunnel; it is typically chronic and progressive.

see acute carpal tunnel syndrome.

Etiology

Osteoid Osteoma, because of its nonspecific presentation in the wrist, it remains a diagnostic challenge. Basran et al. report an unusual case of Osteoid Osteoma at distal radius having symptoms resembling that of carpal tunnel syndrome. The diagnosis was confirmed preoperatively with X-rays; bone scintigraphy, CT, and MRI, later histological examination confirmed the diagnoses. Surgical excision lead to a dramatic improvement in the condition of the patient 1)

Scores

Visual analog scale to assess the intensity of pain and paresthesia symptoms.

Boston Carpal Tunnel Questionnaire (BCTQ)

Michigan Hand Outcome Questionnaire (MHQ)

Quick form of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire,

Duruoz Hand Index (DHI).

The BCTQ, pain and paresthesia results were assumed as gold standards. Correlations between the MHQ, QuickDASH, and the DHI were analyzed. A correlation analysis between the variables was tested using Spearman's rho test or Pearson's test for variables.

The QuickDASH was well correlated with pain, paresthesia and the BCTQ (p<0.001). The questionnaires complied with each other.

In addition to its complicated scoring, the MHQ contained detailed subparameters with similar questions and takes a long time to complete. Further studies may confirm the effective usage of the DHI. The easier QuickDASH questionnaire appears to be more practical for carpal tunnel release patients 2).

Clinical features

Pain, weakness, or numbness in the hand and wrist, radiating up the arm. Although painful sensations may indicate other conditions, carpal tunnel syndrome is the most common and widely known of the entrapment neuropathies in which the body's peripheral nerves are compressed or traumatized.


Carpal tunnel syndrome (CTS) is common in acromegaly and patients have often undergone surgery for CTS prior to the diagnosis of acromegaly.

Zoicas et al. hypothesized that screening CTS-patients for acromegaly could facilitate active case-finding. They prospectively enrolled 196 patients [135 women, 56.9 (range 23-103) years] who presented with CTS for surgery. Patients were asked about 6 symptoms suggestive of acromegaly using a questionnaire calculating a symptom score (0-6 points), and insulin-like-growth factor 1 (IGF-1) was measured. If IGF-1 was increased, IGF-1 measurement was repeated, and random growth hormone (GH) and/or an oral glucose tolerance test (OGTT) with assessment of GH-suppression were performed. The mean symptom score was 1.7±1.3 points. Three patients reported the maximal symptom score of 6 points, but none of them had an increased IGF-1. There was no correlation between the symptom score and IGF-1-SDS (standard deviation score) (r=0.026; p=0.71). Four patients had an IGF-1>2 SDS. In 2 patients acromegaly was ruled out using random GH and OGTT. One patient had normal IGF-1 and random GH at follow-up. One patient refused further diagnostics. In this prospective cohort of patients with CTS, the observed frequency of acromegaly was at most 0.51% (95% CI 0.03 to 2.83%). In this prospective study, none of the 196 patients with CTS had proven acromegaly. Thus, we see no evidence to justify general screening of patients with CTS for acromegaly 3).

Clinical tests

wrist flexion, wrist extension, Tinel's, tethered median nerve (TMN), pinch, vibration and Semmes-Weinstein monofilament (SWMF) tests. Substantial inter-rater agreement was observed between two therapists for five of the clinical tests (k > 0.71) with SWMF and TMN having lower agreement. The most accurate test was Phalen's wrist flexion test. Good accuracy was demonstrated by pinch and vibration tests. Tinel's test was characterized by lower sensitivity, but false positives were rare. Wrist extension and TMN tests had poor sensitivity. SWMF testing was very sensitive, but a high number of false positives occurred when 'normal' was classified as 2.83. Reliability and accuracy of these tests supports their use as components of a clinical diagnosis of CTS 4).

Diagnosis

Diagnosis of CTS is usually based on a combination of clinical symptoms and electrodiagnostic study (EDS).

Ultrasonography criteria have become increasingly useful for the diagnosis.

Ultrasonography

Ultrasonography is better tolerated, less expensive, yet just as effective as other diagnostic methods. It provides a good indication of the severity of the condition and it allows anatomical variants to be discerned. In light of this, for a number of medical professionals it is the first-line examination. In terms of therapeutic use, ultrasound can be used to guide infiltrations. In case medical treatment is unsuccessful, release by transection of the flexor retinaculum is generally done surgically as an open procedure or by endoscopy. A new minimally invasive percutaneous treatment to release the nerve based on ultrasonography guided or ultrasound surgery appears to be a promising alternative, however, to conventional open surgery or endoscopic treatments. 5).

Ultrasonography (US) also has been shown to be a useful diagnostic tool in CTS and is based on an increase in the median nerve cross-sectional area (CSA) at the level of the pisiform bone.

It is expected that sonography may serve as an additional or complementary method which is useful and reliable in assessing the severity of CTS 6), whether such ultrasound data can indicate the severity of carpal tunnel syndrome remains controversial.

Zhang et al. hypothesized that the ratio of the cross-sectional areas of the median nerve at the carpal tunnel inlet to outlet accurately reflects the severity of carpal tunnel syndrome. To test this, high-resolution ultrasound with a linear array transducer at 5-17 MHz was used to assess 77 patients with carpal tunnel syndrome. The results showed that the cut-off point for the inlet-to-outlet ratio was 1.14. Significant differences in the inlet-to-outlet ratio were found among patients with mild, moderate, and severe carpal tunnel syndrome. The cut-off point in the ratio of cross-sectional areas of the median nerve was 1.29 between mild and more severe (moderate and severe) carpal tunnel syndrome patients with 64.7% sensitivity and 72.7% specificity. The cut-off point in the ratio of cross-sectional areas of the median nerve was 1.52 between the moderate and severe carpal tunnel syndrome patients with 80.0% sensitivity and 64.7% specificity. These results suggest that the inlet-to-outlet ratio reflected the severity of carpal tunnel syndrome 7).

Differential diagnosis

Carpal tunnel syndrome vs. C6 radiculopathy.

Treatment

see Neurodynamics for carpal tunnel syndrome.

see Carpal tunnel release

Outcome

see Carpal tunnel syndrome outcome.

1)
Basran SS, Kumar S, Jameel J, Sajid I. Carpal tunnel syndrome: A rare manifestation of distal radius osteoid osteoma. J Clin Orthop Trauma. 2015 Sep;6(3):190-4. doi: 10.1016/j.jcot.2015.03.002. Epub 2015 Apr 7. PubMed PMID: 26155056.
2)
Yücel H, Seyithanoğlu H. Choosing the most efficacious scoring method for carpal tunnel syndrome. Acta Orthop Traumatol Turc. 2015;49(1):23-29. doi: 10.3944/AOTT.2015.13.0162. PubMed PMID: 25803249.
3)
Zoicas F, Kleindienst A, Mayr B, Buchfelder M, Megele R, Schöfl C. Screening for Acromegaly in Patients with Carpal Tunnel Syndrome: A Prospective Study (ACROCARP). Horm Metab Res. 2016 Jul;48(7):452-6. doi: 10.1055/s-0042-100913. Epub 2016 Feb 5. PubMed PMID: 26849823.
4)
Macdermid JC, Kramer JF, McFarlane RM, Roth JH. Inter-rater agreement and accuracy of clinical tests used in diagnosis of Carpal Tunnel Syndrome. Work. 1997 Jan 1;8(1):37-44. PubMed PMID: 24441779.
5)
Petrover D, Richette P. Treatment of carpal tunnel syndrome: from ultrasonography to ultrasound surgery. Joint Bone Spine. 2017 Nov 15. pii: S1297-319X(17)30192-6. doi: 10.1016/j.jbspin.2017.11.003. [Epub ahead of print] PubMed PMID: 29154980.
6)
Ghasemi M, Abrishamchi F, Basiri K, Meamar R, Rezvani M. Can we define severity of carpal tunnel syndrome by ultrasound? Adv Biomed Res. 2015 Jul 27;4:138. doi: 10.4103/2277-9175.161537. eCollection 2015. PubMed PMID: 26322286.
7)
Zhang L, Rehemutula A, Peng F, Yu C, Wang TB, Chen L. Does the ratio of the carpal tunnel inlet and outlet cross-sectional areas in the median nerve reflect carpal tunnel syndrome severity? Neural Regen Res. 2015 Jul;10(7):1172-6. doi: 10.4103/1673-5374.160117. PubMed PMID: 26330845.
carpal_tunnel_syndrome.txt · Last modified: 2019/05/03 18:35 by administrador