Carpal tunnel syndrome: comparison of intraoperative structural changes with clinical and electrodiagnostic severity

The aim of this study is to grade the intraoperative findings seen in carpal tunnel syndrome (CTS) based on severity, and compare it with clinical and electrodiagnostic severity.Thirty-one hands surgically treated for CTS were graded according to the severity of clinical signs, and electrodiagnostic tests. Oedema, vascularisation, and fibrosis were graded on a scale of 1–3. Pseudoneuroma or ‘hour-glass’ formation were graded as either 0 or 1. The hands were allocated by an observer into an assumptive severity group, from grade 1 to 3. Clinical severity and electrodiagnostic severity were statistically compared with each other, and with each intraoperative severity criteria.A high statistical correlation (p<0.01) was found between clinical severity and vascularisation, fibrosis, and the assumptive intraoperative severity. No correlation could be demonstrated between electrodiagnostic severity and the intraoperative criteria.Intraoperative grading should be regarded as a supportive measure to the clinical evaluation in order to obtain a sound base for surgical intervention and internal neurolysis.     

Anatomic investigation of the role of the lumbrical muscles in carpal tunnel syndrome

This study investigates whether the proximal origins of the lumbrical muscles contribute significantly to the etiology of carpal tunnel syndrome. We explored the carpal canals of 128 hands in patients undergoing carpal tunnel release for carpal tunnel syndrome. The origins of the lumbrical muscles were examined at the time of surgery and their relation to the transverse carpal ligament was recorded in all cases. Also, 40 cadaveric hands were dissected to determine the lumbrical muscle origins. In the hands of patients with idiopathic carpal tunnel syndrome, the lumbrical muscle origins were located significantly more proximal in the canal than were the muscles in the cadaveric hands. Younger patients whose jobs required repetitive hand motions had large lumbrical muscles and origins that were more proximal than the lumbricals found in the hands of fresh cadavers.     

A bout of resistance exercise increases urinary calcium independently of osteoclastic activation in men

Outcome after carpal tunnel surgery was studied retrospectively in 32 patients with peripheral neuropathy and carpal tunnel syndrome. Nocturnal paresthesias were almost universally relieved, followed in order of responsiveness by pain, numbness, and weakness. Twenty-five of 28 patients said they would have the surgery again if the outcome were the same. Patients with carpal tunnel syndrome and peripheral neuropathy benefit from surgical treatment of carpal tunnel syndrome.     

A novel growth-factor-dependent myeloid cell line derived from mouse bone marrow cells contains progenitors endowed with high proliferative potential

We describe two modified methods for median-to-ulnar motor conduction comparison in the diagnosis of median neuropathy at the wrist: the median-thenar to ulnar-thenar latency difference (TTLD), and the median-thenar to ulnar-hypothenar latency difference (THLD). We also describe an F-wave ulnar-to-median comparative test, the F-wave latency difference (FWLD). The abnormal cutoffs based upon 34 normal controls are: TTLD, 0.8 ms; THLD, 1.2 ms; FWLD, 0.6 ms. In 50 patients (79 hands) with clinically defined carpal tunnel syndrome and electrophysiological evidence of median neuropathy at the wrist (based upon a prolonged median nerve palm-wrist latency), the diagnostic sensitivities were: 95-98%, 85-88%, and 75-78%, respectively. These tests are therefore highly sensitive. They are easily performed and require minimal additional effort to incorporate into commonly used clinical electrodiagnostic routines. They may be advantageous when a concomitant polyneuropathy is present, and they may also help avoid technical pitfalls and aid in identification of anatomic variants.     

Outcome assessment for carpal tunnel surgery: the relative responsiveness of generic, arthritis-specific, disease-specific, and physical examination measures

Clinical evaluation of outcome after treatment of carpal tunnel syndrome has not been standardized. To assess the value of various clinical and questionnaire measures for the assessment of outcome after carpal tunnel surgery, we surveyed 22 patients 1 day before and 3 months after carpal tunnel release with the following measures: the Medical Outcomes Study 36-item short form health survey, the Arthritis Impact Measurement Scale, the Brigham and Women's Hospital carpal tunnel questionnaire, wrist range of motion, power pinch grip strength, pressure sensibility, and dexterity. Significant changes, all in the direction of improved health status postoperatively, were noted in the following scales or measures: the Arthritis Impact Measurement Scale pain, satisfaction, health perception, arthritis impact, and symptom scales; the Brigham and Women's Hospital symptom and function scales; the short form health survey's physical role, emotional role, and bodily pain scales; and the measurement of dexterity. In this study, standardized questionnaires were more sensitive to the clinical change produced by carpal tunnel surgery than many commonly performed physical measures of outcome. The condition-specific questionnaire was more sensitive to change than were more generic questionnaires.     

Carpal tunnel syndrome, humeral epicondylitis, and the cervical spine: a study of clinical and dimensional relations

Forty-three patients with idiopathic carpal tunnel syndrome, confirmed by nerve conduction studies and treated by surgery, were compared clinically and radiologically with 43 age- and sex-matched control patients. Patients with carpal tunnel syndrome had a significantly greater prevalence of lateral humeral epicondylitis (tennis elbow) (33%) than controls (7%). Randomised reading of the cervical spine radiographs in ignorance of the groups to which they belonged showed no significant difference in the prevalence of either intervertebral disc degeneration or intraforaminal osteophyte protruion using conventional grading methods. Measurement of the minimum anteroposterior diameter of the cervical spinal canal, the anteroposterior diameters of the cervical vertebral bodies, and the ratio of intervertebral disc height to adjacent vertebral body height in the cervical spine, however, showed a consistent trend to smaller measurements in the carpal tunnel group. Differences were significant at several vertebral levels in each of these dimensions. The narrowing of the intervertebral discs relative to the vertebral bodies in patients with carpal tunnel syndrome may indicate connective tissue changes, which might also occur in the common extensor origin at the elbow or in the contents of the carpal tunnel.     

A comparison of traditional electrodiagnostic studies, electroneurometry, and vibrometry in the diagnosis of carpal tunnel syndrome

In 49 patients (98 hands), referred to an electrodiagnostic laboratory, assessments were made by conventional nerve conduction studies on the upper extremity and by two more portable modalities, namely electroneurometry (skin surface electrical stimulation of the motor nerve) and single-frequency (120 Hz) vibrometry. Tests were performed on median and ulnar nerves. Correlations with motor nerve conduction studies for each screening test on the median nerve were r = .81 for the electroneurometer and r = .48 for the vibrometer. When carpal tunnel syndrome was diagnosed either by clinical criteria only or by nerve conduction abnormality, the association with electroneurometry was characterized by high sensitivity and low specificity, while the opposite relationship prevailed with vibrometry. These associations were highly dependent on the methods used to select normal values from a reference population. While the manufacturer's recommended normal values offered good predictability, with thresholds that corresponded to nerve conduction studies, normal values generated in a more standard way produced much weaker and less useful associations. The selection of an appropriate electrical screening test for peripheral nerve injury, such as entrapment neuropathy, depends on the prevalence and seriousness of the target disease and the relative consequences of over- and underdiagnosis.     

Natural history of median nerve sensory conduction in industry: relationship to symptoms and carpal tunnel syndrome in 558 hands over 11 years

We evaluated the natural history of median nerve sensory conduction, hand/wrist symptoms, and carpal tunnel syndrome (CTS) in an 11-year longitudinal study of 289 workers from four industries. Twenty hands which had carpal tunnel release surgery were excluded, leaving 558 hands for the primary study group. Overall, the trend was for mean sensory latencies and prevalence of slowing to increase, the prevalence of symptoms to decrease, and the prevalence of CTS to remain unchanged. Among individual hands, nerve conduction abnormalities tended to persist (82% 11-year persistence), while symptoms fluctuated widely (13% 11-year persistence). There was a strong, direct linear correlation between initial severity of slowing and subsequent development of CTS; however, most workers who developed de novo slowing did not develop symptoms or CTS. We conclude that changes in conduction status of the median nerve occur naturally with increasing age and do not necessarily lead to symptoms and CTS.     

Severe non-ketotic hyperosmolar coma--intensive care management

We prospectively studied 266 hands in 133 patients with carpal tunnel syndrome (CTS) in order to evaluate: the incidence of bilateral CTS symptoms; correlation between severity, duration of symptoms and bilateral occurrence of CTS; agreement of clinical and neurophysiological findings; and the neurophysiological findings in asymptomatic hands in unilateral CTS. The incidence of bilateral clinical CTS in our population was 87%. Neurophysiological impairment of median nerve was observed in about half of the asymptomatic hands. Follow-up of patients with unilateral CTS showed that contralateral symptoms developed in most cases. We found a significant positive correlation of bilateral CTS with the duration of symptoms, whereas there was no correlation with the severity of symptoms. Our data suggest that bilateral impairment of median nerve is the rule in patients with CTS and probably it has been underestimated in previous studies.     

Correlation of clinical history and electrodiagnostic abnormalities with outcome after surgery for carpal tunnel syndrome

A retrospective study on 294 wrists in 154 patients who had been diagnosed with carpal tunnel syndrome and subsequently had surgery performed was undertaken; both clinical and electrodiagnostic findings were correlated. The cases were divided into three groups based on electromyographic severity (mild, moderate, severe), and recovery from symptoms was evaluated after 1 week, 3 months, and 1 year. The cases were also divided into five groups based on symptom duration, and the same investigations were performed. All operations were conducted by applying the open release method with the limited-palmar incision technique. Operative outcomes showed no association between recovery from symptoms and the severity of electromyographic findings or the duration of symptoms, although the group that had the shortest duration of symptoms recovered faster than the long-duration groups statistically. Postoperative results after 1 year were also successful for those patients who had had symptoms of long duration. Of the 294 wrist operations studied, good to excellent postoperative outcomes were recorded in 242 cases (82 percent), fair outcomes in 39 cases (13 percent), and poor outcomes in 13 cases (4 percent). Patients whose electromyogram revealed double crush syndrome still showed improvement, with good-to-excellent results in 11 out of 15 cases (73 percent). Patients with diabetes mellitus also showed improvement, with good-to-excellent results in 14 out of 19 patients (74 percent). This study showed that postoperative results were satisfactory within 1 year, regardless of the degree of electromyographic severity, symptom duration, presence of diabetes mellitus, or double crush syndrome.     

The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome

The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence between the median nerve and overlying transverse carpal ligament and surgical scar. This retrospective study reviews 62 hands in 58 patients (46 non-workers' compensation and 16 workers' compensation) with recurrent symptoms after failed open carpal tunnel release who underwent revision carpal tunnel decompression and in whom a hypothenar fat pad flap was used. The follow-up period averaged 33 months. Patient satisfaction was 6 in the non-workers' compensation group and 4 in the workers' compensation group. Average time to return to work for the non-workers' compensation group was 12 weeks, compared to 37 weeks for the workers' compensation group. Study results indicate that the hypothenar fat pad flap produces excellent results in procedures designed to alleviate recalcitrant idiopathic carpal tunnel syndrome.     

In favor of annual screening for cancer of the cervix uteri

A case of polymyalgia rheumatica with atypical manifestations, including carpal tunnel syndrome, distal myalgias and a low eritro sedimentation is reported. The association of polymyalgia rheumatica and carpal tunnel syndrome is controversial. Although it has been reported previously in a recent and large review of carpal tunnel syndrome in Rochester, USA, there was not any more cases of polymyalgia rheumatica associated with carpal tunnel syndrome than in the general population. In our patient, the symptoms of polymyalgia rheumatica and of carpal tunnel syndrome were present at the beginning, and both responded satisfactorally to the treatment with methylprednisone. This form of presentation and its response to treatment suggest that the symptoms of carpal tunnel syndrome are caused by the inflammation of the carpal synovial, which is an unfrequent manifestation of polymyalgia rheumatica. We report this case for the purpose of altering to an unusual form of presentation of polymyalgia rheumatica in order to avoid unnecessary surgery for the carpal tunnel syndrome.     

Metaphor: the language of nursing researchers

BACKGROUND: The present study determines the association of obesity, gender, age and occupation in patients with carpal tunnel syndrome (CTS) in a New Zealand population. METHODS: Analysis of questionnaires and clinical review of patients who had undergone surgical decompression of the median nerve in the carpal tunnel. RESULTS: The age and gender distribution of 655 hands (512 patients) that had undergone carpal tunnel release (CTR) were compared with the age and gender distribution of the New Zealand population. The results indicate that the 3-year-period prevalence of CTS in females is more than double that in males. Proportionally there were more patients over age 55 than in the general population. The findings also indicate that, proportionally, six times the number of females who worked in moderate manual work underwent CTR compared with the general female population and proportionally twice the number of males who worked in heavy office/clerical work underwent CTR compared with the general male population. It was also found that CTR patients are twice as likely to be overweight (body mass index [BMI] > 25) than the general population and female patients are twice as likely to be obese (BMI > 30) than the general population. CONCLUSIONS: Carpal tunnel syndrome is more than twice as common in females as it is in males, and patients aged more than 55 years are more likely to suffer from CTS. Females with CTS are more likely to work in moderate manual work and males with CTS are more likely to work in heavy office/clerical work. Obesity and CTS are related statistically.     

Change in bacterial community during biodegradation of aniline

A modification of the standard electrodiagnostic test was developed in an effort to provide a more sensitive electrodiagnostic evaluation in radial tunnel syndrome. Radial motor nerve latency recordings were obtained in 3 different forearm positions: neutral, passive supination, and passive pronation. The maximal difference in these recordings, the differential latency, in 25 patients with radial tunnel syndrome of greater than 6 months duration (test group) was compared with those in 25 asymptomatic volunteers (control group). Differential latency recordings were obtained in all patients in the test group before and after surgery. Radial nerves that were compressed demonstrated a significantly greater differential latency (0.44+/-0.12 ms) versus controls (0.12+/-0.008 ms). Following radial nerve decompression, differential motor latencies in the test group decreased below control values, demonstrating a resolution of the provoked electrical response with a postoperative differential latency of 0.07+/-0.05 ms. Our results demonstrate the differential motor latency of the radial nerve to be a sensitive electrodiagnostic tool in patients with radial tunnel syndrome. A differential latency of > or =0.30 ms was considered indicative of radial tunnel syndrome.     

Surgical treatment results in patients with severe forms of the carpal tunnel syndrome

A retrospective and prospective study was undertaken to determine efficacy of carpal tunnel decompression in patients with advanced carpal tunnel syndrome (CTS). The criteria for inclusion in this study were clinical and nerve conduction studies (NCS). Between 1985-1991, 1511 NCSs performed were positive for CTS.     

Predictors of rate of return to work after surgery for carpal tunnel syndrome

OBJECTIVE: To evaluate the impact of patient demographics, clinical features, and job-related factors on the time until return to work after carpal tunnel release surgery. METHODS: We employed a cross-sectional community-based study of 59 patients who had undergone carpal tunnel release surgery. Sociodemographic, clinical, and job-related characteristics and time to return to work were obtained by interview and from medical records. Exposure to ergonomic risk was derived from an independently validated job matrix. Time to return to work after surgery was analyzed by survival techniques. RESULTS: Median time to return to work was 5 weeks. After adjustment, the relative rate (RR) of return to work per week after surgery was most strongly decreased by the receipt of workers' compensation, RR 0.2 (95% confidence interval [CI] 0.1-0.5), and by the exposure to bending and twisting of the hand prior to surgery, RR 0.7 (95% CI 0.5-0.9) per hour. Female gender was another predictor of decreased return to work, RR 0.5 (95% CI 0.3-0.8). CONCLUSIONS: Patients receiving workers' compensation, those exposed to higher levels of bending and twisting of their hands and wrists, and women were slower to return to work after carpal tunnel release surgery.     

Entrapment neuropathies

Relative frequency of entrapment neuropathies was studied from amongst the patients referred to an electrodiagnostic medicine laboratory for electrophysiological studies. During the study period electrophysiological procedures were done on 650 patients with various peripheral nerve disorders. The entrapment neuropathies constituted 8.5%. Carpal tunnel syndrome (CTS) was the commonest entrapment neuropathy (83.6%). Diagnosis of CTS was established in 84 Patients referred with the diagnosis of CTS. Electrophysiological tests confirmed the diagnosis of thoracic outlet syndrome in 4 (15.4%) of the 26 patients referred with this diagnosis and in 5 (19.3%) of them the diagnosis turned out to be CTS. Diagnosis of cubital tunnel syndrome was not suspected clinically in all the 3 patients, they were referred with the diagnosis of ulnar neuropathy. In both the patients with tarsal tunnel syndrome the initial diagnosis was peripheral neuropathy.     

Responsiveness of self-reported and objective measures of disease severity in carpal tunnel syndrome

Responsiveness, the ability to detect meaningful clinical change, is a critical attribute of instruments used to evaluate outcomes of treatments. The authors hypothesized that self-administered symptom severity and functional status questionnaires are more responsive to clinical improvement after carpal tunnel release than traditional physical examination measures of strength and sensibility. Data were obtained from a randomized clinical trial of endoscopic versus open carpal tunnel release conducted in four university medical centers. Patients were evaluated before surgery and 3 months after surgery. Seventy-four patients indicating that they were more than 80% satisfied with the results of surgery were assumed to have clinically meaningful improvement and were the focus of the analysis. Evaluations included questionnaires assessing symptom severity, functional status, and activities of daily living as well as measurement of grip, pinch, and abductor pollicus brevis strength, and 2-point discrimination and Semmes-Weinstein pressure sensibility. Responsiveness was calculated with the standardized response mean (mean change/standard deviation of change) as well as the effect size (mean change/standard deviation of baseline values). The symptom severity scale was four times as responsive, and the functional status and activities of daily living scales were twice as responsive, as the measures of strength and sensibility. Self-administered symptom severity and functional status scales are much more responsive to clinical improvement than measures of neuromuscular impairment and should severe as primary outcomes in clinical studies of therapy for carpal tunnel syndrome.     

Unilateral vs. bilateral carpal tunnel: challenges and approaches

Conditions affecting either or both extremities offer unique opportunities and challenges for investigators and clinicians. When the condition is purely unilateral, observations on the unaffected extremity may be used as a within-patient control, and thereby strengthen the ability to identify changes in the affected limb. However, such use presumes that the condition will not subsequently develop in the unaffected extremity. Bilateral presentations or subsequent development of disease in the unaffected extremity is common in conditions such as the carpal tunnel syndrome (CTS). Treatment of one extremity may lead to development or aggravation of CTS in the other extremity. Since both extremities may be necessary to perform certain activities, it can be difficult to clearly identify treatment effects when looking at functional outcomes. In an effort to avoid these complexities, investigators have used one of two approaches in studying CTS: either selecting only those patients with unilateral disease, or analyzing results by extremity, often avoiding any outcome measures that might depend upon both extremities (such as driving). We illustrate some of the shortcomings of this approach, such as loss of patients and data, with preliminary information from our ongoing prospective study of carpal tunnel surgery outcomes. We develop a dynamic model that incorporates etiologic factors and treatment effects to describe changes in CTS over time. This model accounts for extremity-specific and systemic factors, as well as possible interaction of the disease process in both hands. The advantages of this model include a more rational approach to research and care of extremity disorders, and research strategies which address a wider scope of patients and outcomes; however, its application is limited by the need for more extensive data collection.     

Pulmonary veno-occlusive disease complicating Felty''s syndrome

Correction factors exist to allow for the dramatic effect that temperature has on nerve conduction study parameters. However, these are based on normal nerves in normal individuals and may not be appropriate in the diseased nerve setting. Our clinical study showed that in carpal tunnel syndrome, the median nerve reacts differently to temperature changes compared with normal ulnar controls. Furthermore, statistically significant differences exist between the rates of change with increasing temperature in motor and sensory nerves.