"Recent research regarding how to treat carpal tunnel syndrome is scanned daily from major neurology journals and updated here"
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Carpal tunnel syndrome and keyboard use at work: a population-based study.
Arthritis Rheum. 2007 Nov;56(11):3620-5
Authors: Atroshi I, Gummesson C, Ornstein E, Johnsson R, Ranstam J
OBJECTIVE: To investigate the relationship between carpal tunnel syndrome (CTS) and keyboard use at work in a general population. METHODS: A health status questionnaire was mailed to 2,465 persons of working age (25-65 years) who were randomly selected from the general population of a representative region of Sweden. The questionnaire required the subjects to provide information about the presence and severity of pain, numbness and tingling in each body region, employment history, and work activities, including average time spent using a keyboard during a usual working day. Those reporting recurrent hand numbness or tingling in the median nerve distribution were asked to undergo a physical examination and nerve conduction testing. The prevalence of CTS, defined as symptoms plus abnormal results on nerve conduction tests, was compared between groups of subjects that differed in their intensity of keyboard use, adjusting for age, sex, body mass index, and smoking status. RESULTS: Eighty-two percent responded to the questionnaire, and 80% of all symptomatic persons attended the examinations. Persons who had reported intensive keyboard use on the questionnaire were significantly less likely to be diagnosed as having CTS than were those who had reported little keyboard use, with a prevalence that increased from 2.6% in the highest keyboard use group (> or = 4 hours/day), to 2.9% in the moderate use group (1 to <4 hours/day), 4.9% in the low use group (<1 hour/day), and 5.2% in the no keyboard use at work group (P for trend = 0.032). Using > or = 1 hour/day to designate high keyboard use and <1 hour/day to designate low keyboard use, the prevalence ratio of CTS in the groups with high to low keyboard use was 0.55 (95% confidence interval 0.32, 0.96). CONCLUSION: Intensive keyboard use appears to be associated with a lower risk of CTS.
Treat carpal tunnel syndrome PMID: 17968917 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Carpal tunnel syndrome in spine surgeons: a pilot study.
Arch Environ Occup Health. 2006 Nov-Dec;61(6):259-62
Authors: Forst L, Friedman L, Shapiro D
The goal of this project was to determine risk factors for carpal tunnel syndrome (CTS) in spine surgeons. Members of the North American Spine Society participated in a questionnaire survey in the Spring of 2004. There were 107 reported cases of CTS. The authors observed a linear dose response (p < .01) between hours of work and CTS. Predictors were obesity (body mass index > or = 30; adjusted odds ratio [OR] = 2.04, 95% confidence interval [CI] = 1.11-3.76) and practicing surgery for > 5 years (adjusted OR = 4.24, 95% CI = 1.54-11.69). The authors identified the use of the Kerrison rongeur (a bone-removal tool) as the greatest ergonomic risk for the surgeons (adjusted OR = 2.72, 95% CI = 1.54-4.81), and 37% of them reported that CTS interferes with their work. Ergonomic interventions for CTS should be evaluated in the operating room.
Treat carpal tunnel syndrome PMID: 17967747 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Reduced longitudinal excursion of the median nerve in carpal tunnel syndrome.
Arch Phys Med Rehabil. 2007 Nov;88(11):1542
Authors: LaBan MM
Treat carpal tunnel syndrome PMID: 17964902 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
Arch Phys Med Rehabil. 2007 Nov;88(11):1429-35
Authors: Brininger TL, Rogers JC, Holm MB, Baker NA, Li ZM, Goitz RJ
OBJECTIVE: To compare the effects of a neutral wrist and metacarpophalangeal (MCP) splint with a wrist cock-up splint, with and without exercises, for the treatment of carpal tunnel syndrome (CTS). DESIGN: A 2x2x3 randomized factorial design with 3 main factors: splint (neutral wrist and MCP and wrist cock-up), exercise (exercises, no exercise), and time (baseline, 4wk, 8wk). SETTING: Subjects were evaluated in an outpatient hand therapy clinic. PARTICIPANTS: Sixty-one subjects with mild to moderate CTS; 51 subjects completed the study. INTERVENTIONS: There were 4 groups: the neutral wrist and MCP group and the neutral wrist and MCP-exercise group received fabricated customized splints that supported the wrist and MCP joints; the wrist cock-up group and the wrist cock-up-exercise group received wrist cock-up splints. The neutral wrist and MCP-exercise and wrist cock-up-exercise groups also received tendon and nerve gliding exercises and were instructed to perform exercises 3 times a day. All subjects were instructed to wear the assigned splint every night for 4 weeks. MAIN OUTCOME MEASURES: We used the CTS Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) to assess CTS symptoms and functional status. RESULTS: Analysis of variance showed a significant main effect for splint and time on the SSS (P<.001, P=.014) and FSS (P<.001, P=.029), respectively. There were no interaction effects. CONCLUSIONS: Our results validate the use of wrist splints for the treatment of CTS, and suggest that a splint that supports the wrist and MCP joints in neutral may be more effective than a wrist cock-up splint.
Treat carpal tunnel syndrome PMID: 17964883 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Conflicting evidence on splints for carpal tunnel syndrome.
Am Fam Physician. 2007 Aug 15;76(4):499; author reply 499-500, 503; discussion 503
Authors: Van Zandt KB
Treat carpal tunnel syndrome PMID: 17853623 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Carpal tunnel syndrome: Nerve studies are not that useful in diagnosis.
BMJ. 2007 Sep 1;335(7617):414
Authors: Mahaffey PJ
Treat carpal tunnel syndrome PMID: 17762012 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Carpal tunnel syndrome.
BMJ. 2007 Aug 18;335(7615):343-6
Authors: Bland JD
Treat carpal tunnel syndrome PMID: 17703044 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Use of quantitative abductor pollicis brevis strength testing in patients with carpal tunnel syndrome.
Plast Reconstr Surg. 2007 Apr 1;119(4):1277-83
Authors: Liu F, Watson HK, Carlson L, Lown I, Wollstein R
BACKGROUND: Diagnosis of carpal tunnel syndrome remains clinical, despite many objective clinical and electrophysiologic tests. There is also a need to objectively assess the severity of involvement and the need for surgery, and to document response to treatment. The authors evaluated a hand-held strength-testing device for assessment of abductor pollicis brevis strength in patients with carpal tunnel syndrome. METHODS: Sixty-two hands in 50 patients (39 women and 11 men) aged 26 to 57 years were examined. All hands were evaluated before and 6 weeks after surgery. Nineteen hands were available for 7-year follow-up. RESULTS: Abductor pollicis brevis strength following carpal tunnel release increased significantly from a mean of 2.3 kg to 3.1 kg. The strength further increased in all long-term follow-up patients. CONCLUSIONS: Quantitative strength testing can be used to document changes in abductor pollicis brevis strength in response to treatment in patients with carpal tunnel syndrome. Further study is needed to assess the reliability of this testing method using multiple examiners in patients with carpal tunnel syndrome, and to evaluate the utility of using this device in tracking the long-term outcome of patients after carpal tunnel release.
Treat carpal tunnel syndrome PMID: 17496602 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Arch Phys Med Rehabil. 2007 May;88(5):569-76
Authors: Hough AD, Moore AP, Jones MP
OBJECTIVE: To determine if longitudinal excursion of the median nerve is reduced in patients with carpal tunnel syndrome (CTS). DESIGN: Case-control study. SETTING: University human movement laboratory. PARTICIPANTS: Nineteen patients with CTS (8 men, 11 women; mean age, 57+/-15 y), and 37 healthy controls (8 men, 29 women; mean age, 48+/-10 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Longitudinal excursion of the median nerve, and the ratio of nerve to flexor digitorum superficialis tendon excursion at the carpal tunnel evoked by finger extension. Measurements were taken using a validated Doppler ultrasound technique, and tests were conducted with the elbow positioned in extension and flexion. RESULTS: Mean longitudinal excursion of the median nerve was significantly greater in controls (11.2+/-2.8 mm) than patients (8.3+/-2.6 mm) with the elbow extended (P=.013), but not with the elbow flexed (controls, 12.5+/-2.5 mm; patients, 10.2+/-3.1 mm; P=.089). Mean nerve/tendon excursion ratios were significantly greater in controls (.32+/-.07) than patients (.23+/-.06), with the elbow extended (P<.001), and flexed (controls, .36+/-.06; patients, .28+/-.10; P=.019). Discriminant analysis identified that 11 (58%) of the 19 patients and 3 (8%) of the 37 controls showed a nerve/tendon excursion ratio of .25 or less when tested with the elbow in extension. CONCLUSIONS: Reduced longitudinal excursion of the median nerve at the carpal tunnel was identified in a substantial proportion of patients with CTS. Further studies are merited to determine if reduced median nerve excursion at the carpal tunnel is clinically relevant in CTS, and can be influenced by movement-based interventions.
Treat carpal tunnel syndrome PMID: 17466724 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Acute carpal tunnel syndrome preceded by 5 years of unusual skin changes.
Arch Neurol. 2007 Mar;64(3):447
Authors: Nettrour JF, Eggers SD, Pittelkow MR, Matteson EL
Treat carpal tunnel syndrome PMID: 17353393 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Am Fam Physician. 2007 Feb 1;75(3):381-3
Authors: Ashworth N
Treat carpal tunnel syndrome PMID: 17304871 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Second lumbrical muscle recordings improve localization in severe carpal tunnel syndrome.
Arch Phys Med Rehabil. 2007 Feb;88(2):259-61
Authors: Brannegan R, Bartt R
OBJECTIVE: To determine how often the second lumbrical motor potential is present when the abductor pollicis brevis (APB) motor potential is absent in severe carpal tunnel syndrome (CTS). DESIGN: Prospective study of consecutive patients with severe CTS and an absent motor potential from the APB. SETTING: Single-center public hospital-based electromyography lab. PARTICIPANTS: Patients with a clinical diagnosis of CTS who had an absent median sensory response and an absent median motor response to APB on routine nerve conduction testing. Twenty-two hands of 19 patients were examined. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Presence and distal latency of motor potential to the second lumbrical. RESULTS: The second lumbrical potential was present in 17 hands (77%). The distal motor latency to the second lumbrical was prolonged in all (mean, 9.1ms; normative value, <4.1ms). CONCLUSIONS: Second lumbrical recordings improve localization in many patients with severe CTS when routine median sensory and motor conduction studies produce no potentials.
Treat carpal tunnel syndrome PMID: 17270527 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
The relationship between electrodiagnostic findings and patient symptoms and function in carpal tunnel syndrome.
Arch Phys Med Rehabil. 2007 Jan;88(1):19-24
Authors: Chan L, Turner JA, Comstock BA, Levenson LM, Hollingworth W, Heagerty PJ, Kliot M, Jarvik JG
OBJECTIVE: To examine whether, in patients with carpal tunnel syndrome (CTS), electrodiagnostic study findings were associated with patient symptom severity and functional limitations after controlling for potentially confounding variables including depression, somatization, and pain-related catastrophizing. DESIGN: Cross-sectional design including data from 2 ongoing CTS studies. SETTING: Patients enrolled from hospitals and clinics in Washington State between October 2002 and February 2006. PARTICIPANTS: Adults with CTS (N=215) (based on symptoms and abnormal electrodiagnostic findings) were analyzed. Exclusion criteria were any mass, tumor, severe trauma, or deformity in the hand or wrist, radiculopathy, polyneuropathy, pregnancy, lactation, or severe CTS. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) functional status scale assessed the ability to perform 9 common hand-related tasks. The CTSAQ symptom severity scale included 11 items that assess pain, numbness, and weakness. Patients also rated their average hand and wrist pain in the last month. RESULTS: With and without controlling for patient characteristics, including age, sex, body mass index, symptom duration, depression, somatization, and pain-related catastrophizing, there were no statistically significant relationships between the electrodiagnostic findings and patient functional status and symptom severity. CONCLUSIONS: Electrodiagnostic findings and patient CTS-related symptoms and function appear to be independent measures. Clinicians and researchers interested in CTS outcomes need to assess both.
Treat carpal tunnel syndrome PMID: 17207670 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Changes in the functional structure of the tenosynovium in idiopathic carpal tunnel syndrome: a scanning electron microscope study.
Plast Reconstr Surg. 2006 Nov;118(6):1413-22
Authors: Ettema AM, Amadio PC, Zhao C, Wold LE, O'Byrne MM, Moran SL, An KN
BACKGROUND: The subsynovial connective tissue lies between the flexor tendons and visceral synovium in the carpal tunnel. Although tenosynovial fibrosis is nearly universally noted in patients with carpal tunnel syndrome, the relationship, if any, between the fibrosis and nerve abnormalities is unknown. The authors used light and scanning electron microscope imaging of the subsynovial connective tissue to gather information about its organization. METHODS: Human subsynovial connective tissue was studied to determine its ultrastructural morphology. Biopsy specimens of 11 patients (12 hands) with idiopathic carpal tunnel syndrome, 14 cadaver controls, and two cadavers with a history of carpal tunnel syndrome were obtained for scanning electron microscopic imaging and histopathologic examination. RESULTS: The visceral synovial layer is an uninterrupted membrane that defines the bursa dorsally. The subsynovial connective tissue consists of fibrous bundles that run parallel to the tendon, interconnected by smaller fibrous fibers. It connects to the synovial membrane and the flexor tendons. During tendon motion, the loose fibers between adjacent layers are stretched. The control tissue showed interconnections between all the parallel layers, whereas in patients with idiopathic carpal tunnel syndrome, these interconnections were absent, replaced with thicker parallel fibrous bundles. Similar changes were found in the cadaver carpal tunnel syndrome specimens. Pathologic changes in the patient and cadaver carpal tunnel syndrome specimens were most apparent close to the tendon and became progressively less severe in more superficial layers. CONCLUSIONS: The authors' observation that the most severe changes in the subsynovial connective tissue were found close to the tendon suggests that these changes may be the result of a shearing injury.
Treat carpal tunnel syndrome PMID: 17051112 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Surgery versus conservative therapy in carpal tunnel syndrome in people aged 70 years and older.
Plast Reconstr Surg. 2006 Sep 15;118(4):947-58; discussion 959-60
Authors: Ettema AM, Amadio PC, Cha SS, Harrington JR, Harris AM, Offord KP
BACKGROUND: Carpal tunnel syndrome is common in the general population, with a prevalence that increases with age. Although good satisfaction has been described after carpal tunnel release, little is known about the long-term outcome of treatment in elderly individuals with carpal tunnel syndrome. METHODS: The authors reviewed data from a population-based sample of 102 patients aged 70 years and older with carpal tunnel syndrome. They used valid and sensitive mailed follow-up outcome [Boston Carpal Tunnel, satisfaction (American Academy of Orthopaedic Surgeons), and health status (Short Form-36) questionnaires to assess symptoms, functional status, expectations of treatment, and satisfaction with the results at a minimum of 2 years after initial diagnosis. RESULTS: Seventy patients with a mean age of 77.0 years (range, 70.2 to 88.5 years) responded to the survey, with a mean follow-up of 4.8 years. Patients who had surgery were more likely to have had more severe disease than those treated nonoperatively (Mantel-Haentzel test, p < 0.001).Satisfaction was 93 percent after surgical treatment and 54 percent after nonsurgical treatment. Patients who had surgery had significantly better relief of symptoms (t test, p < 0.01), functional status (t test, p < 0.05), satisfaction (t test, p < 0.001), and expectations with treatment (t test, p < 0.05) scores as compared with those who had nonsurgical treatment. CONCLUSIONS: In patients over the age of 70, surgery appears to be associated with better symptom relief, functional status, satisfaction, and expectations with treatment than nonoperative therapy does. Age should not be considered a contraindication for carpal tunnel surgery, nor should nonoperative therapy be favored in this age group.
Treat carpal tunnel syndrome PMID: 16980856 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
The diagnosis and treatment of carpal tunnel syndrome.
BMJ. 2006 Jun 24;332(7556):1463-4
Authors: Graham B
Treat carpal tunnel syndrome PMID: 16793786 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.
BMJ. 2006 Jun 24;332(7556):1473
Authors: Atroshi I, Larsson GU, Ornstein E, Hofer M, Johnsson R, Ranstam J
OBJECTIVES: To compare endoscopic and open carpal tunnel release surgery among employed patients with carpal tunnel syndrome. DESIGN AND SETTING: Randomised controlled trial at a single orthopaedic department. PARTICIPANTS: 128 employed patients aged 25-60 years with clinically diagnosed and electrophysiologically confirmed idiopathic carpal tunnel syndrome. MAIN OUTCOME MEASURES: The primary outcome was severity of postoperative pain in the scar or proximal palm and the degree to which pain or tenderness limits activities, each rated on a 4 point scale, transformed into a combined score of 0 (none) to 100 (severe pain or tenderness causing severe activity limitation). The secondary outcomes were length of postoperative work absence, severity of symptoms of carpal tunnel syndrome and functional status scores, SF-12 quality of life score, and hand sensation and strength (blinded examiner); follow-up at three and six weeks and three and 12 months. RESULTS: 63 patients were allocated to endoscopic surgery and 65 patients to open surgery, with no withdrawals or dropouts. Pain in the scar or proximal palm was less prevalent or severe after endoscopic surgery than after open surgery but the differences were generally small. At three months, pain in the scar or palm was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat 3.4, 95% confidence interval 2.3 to 7.7) and the mean score difference for severity of pain in scar or palm and limitation of activity was 13.3 (5.3 to 21.3). No differences between the groups were found in the other outcomes. The median length of work absence after surgery was 28 days in both groups. Quality of life measures improved substantially. CONCLUSIONS: In carpal tunnel syndrome, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain.
Treat carpal tunnel syndrome PMID: 16777857 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Predictors of carpal tunnel syndrome: accuracy of gray-scale and color Doppler sonography.
AJR Am J Roentgenol. 2006 May;186(5):1240-5
Authors: Mallouhi A, Pülzl P, Pültzl P, Trieb T, Piza H, Bodner G
OBJECTIVE: The purpose of this study was to retrospectively assess the accuracy of gray-scale and color Doppler sonography in the diagnosis of carpal tunnel syndrome. MATERIALS AND METHODS: A total of 206 wrists in 151 patients with a clinical suspicion of carpal tunnel syndrome were examined with high-resolution sonography using a 7-15-MHz linear array transducer. The presence of median nerve swelling, edema, and flattening and increased bowing of the flexor retinaculum was evaluated with gray-scale sonography, and the presence of nerve hypervascularization was evaluated with color Doppler sonography. Sensitivity and specificity were calculated for each sonographic feature in comparison with nerve conduction studies as the standard of reference. Multivariate logistic regression analysis was used to determine variables predictive of carpal tunnel syndrome. RESULTS: Carpal tunnel syndrome was confirmed in 172 wrists at nerve conduction studies. A median nerve cross-sectional area of at least 0.11 cm2 was calculated as a definition of median nerve swelling. In comparison with nerve conduction studies, nerve swelling showed the highest accuracy (91%) among gray-scale sonography criteria, and the presence of intraneural hypervascularization showed the highest accuracy (95%) among all sonography criteria. Logistic regression analysis showed that nerve hypervascularization was the only variable that independently predicted median nerve entrapment (odds ratio, 16.4; 95% confidence interval, 8.7-31.1; p <0.001). CONCLUSION: Color Doppler sonography is more accurate than gray-scale sonography for characterizing median nerve involvement in patients with suspected carpal tunnel syndrome.
Treat carpal tunnel syndrome PMID: 16632712 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Morphological changes of collagen fibrils in the subsynovial connective tissue in carpal tunnel syndrome.
J Bone Joint Surg Am. 2006 Apr;88(4):824-31
Authors: Oh J, Zhao C, Zobitz ME, Wold LE, An KN, Amadio PC
BACKGROUND: Pathologic changes occur commonly in the subsynovial connective tissue in patients with carpal tunnel syndrome. The purposes of this study were to investigate the ultrastructural changes of the subsynovial connective tissue in these patients and compare them with the findings in cadaver controls. METHODS: The diameter and density of collagen fibrils were measured by transmission electron microscopy in specimens of subsynovial connective tissue from ten patients with idiopathic carpal tunnel syndrome and from ten fresh-frozen cadavers of individuals without known symptoms of carpal tunnel syndrome. RESULTS: We noted deformed collagen fibrils with a spiraled appearance in the specimens from the patients. We also observed phagocytosis of elastin fibrils in all of those specimens. These changes were noted only rarely in the cadaver controls. The mean diameter (and standard deviation) of the collagen fibrils was 45.5 +/- 8.0 nm in the control group and 54.8 +/- 15.2 nm in the patient group (p < 0.05). The mean number of collagen fibrils per 0.04 microm2 (density) was 201.38 +/- 48.88 in the control group and 157.08 +/- 54.38 in the patient group (p < 0.05). CONCLUSIONS: These ultrastructural findings suggest that subsynovial collagen in patients with carpal tunnel syndrome is structurally different from that in individuals without carpal tunnel syndrome, but the processes resulting in that abnormal morphology remain to be elucidated.
Treat carpal tunnel syndrome PMID: 16595473 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome.
Neurology. 2006 Mar 28;66(6):955-6; author reply 955-6
Authors: Andreu JL, Ly-Pen D
Treat carpal tunnel syndrome PMID: 16567731 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Carpal tunnel syndrome in a patient with trichorhinophalangeal syndrome.
Plast Reconstr Surg. 2006 Mar;117(3):36e-39e
Authors: Morritt AN, Saeed WR, Robinson P
Treat carpal tunnel syndrome PMID: 16525252 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Lidocaine patch 5 for carpal tunnel syndrome: how it compares with injections: a pilot study.
J Fam Pract. 2006 Mar;55(3):209-14
Authors: Nalamachu S, Crockett RS, Mathur D
OBJECTIVES: A standard treatment option for mild-to-moderate carpal tunnel syndrome (CTS) is a local injection of anesthetic-corticosteroid, but this can be painful and may cause complications. This pilot clinical trial was designed to compare the safety and efficacy of daily applications of the lidocaine patch 5% to that of a single injection of 0.5 cc lidocaine 1% plus methylprednisolone acetate (Depo-Medrol) 40 mg. METHODS: In this randomized, parallel-group, open-label, single-center, active-controlled, prospective pilot study, participants aged 18-75 years with clinical/electrodiagnostic evidence of CTS were randomized to receive the lidocaine patch 5% or 1 injection of 0.5 cc lidocaine 1% plus Depo-Medrol 40 mg. Outcome assessments included the Brief Pain Inventory (measuring pain intensity, relief, and interference with quality of life, Patient and Global Clinical Impression of Improvement, Global Assessment of Treatment Satisfaction, and safety. RESULTS: Baseline characteristics of the 40 patients randomized to treatment with the lidocaine patch 5% (n=20) or injection (n=20) were similar between groups. After 4 weeks of treatment, patients in both groups reported significant changes (P<.05) in worst pain, average pain, and pain "right now." Composite interference scores, which are measures of how much patients' pain interfered with quality of life, also significantly improved in both treatment groups (patch, -13.9; injection, -16.7; P<.001 vs baseline for both groups). Eighty percent of patients in the lidocaine patch group and 59% of patients who received the injection reported being "satisfied" or "very satisfied," while investigators reported improvement in 88% of patients using the lidocaine patch and in 74% of those who received the injection. Both treatments were well tolerated, with treatment-related adverse events (AEs) reported in 3 patients in each group (15%). No systemic treatment-related AEs were observed with the lidocaine patch 5%. CONCLUSIONS: This pilot trial demonstrated that the lidocaine patch 5% was efficacious in reducing pain associated with CTS and was well tolerated. The lidocaine patch 5% may offer patients with CTS effective, noninvasive treatment for the management of their symptoms. Further controlled trials are warranted.
Treat carpal tunnel syndrome PMID: 16510054 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Treatment of carpal tunnel syndrome: is there a role for local corticosteroid injection?
Neurology. 2006 Feb 14;66(3):459-60; author reply 459-60
Authors: Hoffman DE
Treat carpal tunnel syndrome PMID: 16476965 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Acute progressive bilateral carpal tunnel syndrome after upper respiratory tract infection.
South Med J. 2005 Nov;98(11):1149-51
Authors: El Hajj II, Harb MI, Sawaya RA
This report describes the case of a 32-year-old male presenting with acute progressive bilateral carpal tunnel syndrome after a benign upper respiratory tract infection. Serial nerve conduction studies confirmed progressive entrapment of the median nerves in the carpal tunnel to the point of axonal damage. Surgical decompression relieved the entrapment, and nerve conduction studies improved.
Treat carpal tunnel syndrome PMID: 16351040 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Ultrasonography shows increased cross-sectional area of the median nerve in patients with arthritis and carpal tunnel syndrome.
Rheumatology (Oxford). 2006 May;45(5):584-8
Authors: Hammer HB, Hovden IA, Haavardsholm EA, Kvien TK
OBJECTIVES: To examine whether patients with arthritic diseases and carpal tunnel syndrome (CTS) have increased cross-sectional areas of the median nerves measured by ultrasonography (US). Enlarged cross-sectional areas have previously been found in non-arthritic patients with idiopathic CTS. METHODS: During 1 yr, all 12 patients with rheumatoid arthritis (RA) or other arthritic diseases hospitalized in our department for surgery for CTS were included. Nine of the patients had bilateral CTS, giving a total of 21 pathological nerves. The median duration of CTS symptoms was 9.5 months. The controls were 30 randomly selected RA patients without symptoms of CTS and 30 healthy persons. Both CTS patients and controls were examined bilaterally by use of US at the entrance of the carpal tunnel, and the cross-sectional areas of the median nerves were calculated. RESULTS: Cross-sectional areas of the median nerves were significantly higher in the CTS patients compared with the RA controls and healthy persons; median (range) areas were 15.7 mm(2) (11.1-21.8), 8.5 mm(2) (5.8-11.0) and 8.0 mm(2) (4.9-12.0), respectively (P<0.0001). No significant differences in cross-sectional areas were observed between the two control groups, or between the right and left hand in the control groups. CONCLUSIONS: Higher cross-sectional areas were found in the arthritic patients with CTS than in RA patients and healthy persons without CTS. This supports previous studies of idiopathic CTS in which increased cross-sectional areas have been found. Thus, as in idiopathic CTS, arthritic patients may be examined by US of the median nerve when CTS is suspected.
Treat carpal tunnel syndrome PMID: 16332951 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Thumb strength affected by carpal tunnel syndrome.
Clin Orthop Relat Res. 2005 Dec;441:320-6
Authors: Li ZM, Harkness DA, Goitz RJ
We examined the effects of carpal tunnel syndrome on thumb strength in multiple directions to test the hypothesis that a force deficit would be most severe in directions associated with abduction. Twelve right-handed women with carpal tunnel syndrome in the right hand, and 12 age-matched, gender-matched, right-handed control subjects were included. Thumb strength was measured in all directions in the transverse plane perpendicular to the longitudinal axis of the thumb. Force envelopes, the boundary of maximal force magnitude, were constructed using the directional forces. The force envelope or envelope area did not differ between the control subjects and the patients with carpal tunnel syndrome. The percentage contributions of force quadrant to the envelope area did not differ between the patients and the control subjects. Our results support the concept that thumb strength is relatively preserved with carpal tunnel syndrome, and failed to support the traditional belief that carpal tunnel syndrome preferentially impairs thumb abduction strength. The data suggest the commonly used testing of thumb abduction strength may not be an effective means to evaluate the existence or severity of carpal tunnel syndrome. Level of Evidence: Diagnostic study, Level III (study of nonconsecutive patients; without consistently applied "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.
Treat carpal tunnel syndrome PMID: 16331021 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Estimating the prevalence of carpal tunnel syndrome.
Arthritis Rheum. 2005 Oct 15;53(5):803; author reply 804
Authors: Mattioli S, Fiorentini C, Curti S, Cooke RM, Bonfiglioli R, Violante FS
Treat carpal tunnel syndrome PMID: 16208652 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Determining the sensitivity and specificity of common diagnostic tests for carpal tunnel syndrome using latent class analysis.
Plast Reconstr Surg. 2005 Aug;116(2):502-7
Authors: LaJoie AS, McCabe SJ, Thomas B, Edgell SE
BACKGROUND: The accuracy of a diagnostic test used to classify a patient as having disease or being disease-free is a valuable piece of information to be used by the physician when making treatment decisions. If a standard reference test is available, determining the sensitivity and specificity of a new test is straightforward. However, if that reference test is incorrectly assumed to be perfectly sensitive and specific, the errors of the reference test can result in an underestimation of the accuracy of the test being evaluated. Latent class analysis can be applied to determine the sensitivity and specificity of a new test when no standard exists. METHODS: Latent class analysis was used to determine the accuracy rates of three commonly used measures of carpal tunnel syndrome: Tinel's sign, Phalen's test, and the nerve conduction velocity test. Data included 162 wrists from 81 patients seeking treatment for symptoms associated with carpal tunnel syndrome. RESULTS: Tinel's sign and Phalen's test were both highly sensitive (0.97 and 0.92, respectively) and specific (0.91 and 0.88, respectively). The sensitivity and specificity of the nerve conduction velocity test were 0.93 and 0.87, respectively. CONCLUSION: Estimates of the sensitivity and specificity of these common tests for carpal tunnel syndrome support their widespread clinical use.
Treat carpal tunnel syndrome PMID: 16079681 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Surgery versus steroid injection in carpal tunnel syndrome: comment on the article by Ly-Pen et al.
Arthritis Rheum. 2005 Aug;52(8):2578; author reply 2578-9
Authors: Hui AC, Wong SM
Treat carpal tunnel syndrome PMID: 16059896 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Neurology. 2005 Jun 28;64(12):2074-8
Authors: Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, Li-Tsang CW, Wong LK, Boet R
BACKGROUND: Decompressive surgery and steroid injection are widely used forms of treatment for carpal tunnel syndrome (CTS) but there is no consensus on their effectiveness in comparison to each other. The authors evaluated the efficacy of surgery vs steroid injection in relieving symptoms in patients with CTS. METHODS: The authors conducted a randomized, single blind, controlled trial. Fifty patients with electrophysiologically confirmed idiopathic CTS were randomized and assigned to open carpal tunnel release (25 patients) or to a single injection of steroid (25 patients). Patients were followed up at 6 and 20 weeks. The primary outcome was symptom relief in terms of the Global Symptom Score (GSS), which rates symptoms on a scale of 0 (no symptoms) to 50 (most severe). Nerve conduction studies and grip strength measurements were used as secondary outcome assessments. RESULTS: At 20 weeks after randomization, patients who underwent surgery had greater symptomatic improvement than those who were injected. The mean improvement in GSS after 20 weeks was 24.2 (SD 11.0) in the surgery group vs 8.7 (SD 13.0) in the injection group (p < 0.001); surgical decompression also resulted in greater improvement in median nerve distal motor latencies and sensory nerve conduction velocity. Mean grip strength in the surgical group was reduced by 1.7 kg (SD 5.1) compared with a gain of 2.4 kg (SD 5.5) in the injection group. CONCLUSION: Compared with steroid injection, open carpal tunnel release resulted in better symptomatic and neurophysiologic outcome but not grip strength in patients with idiopathic carpal tunnel syndrome over a 20-week period.
Treat carpal tunnel syndrome PMID: 15985575 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Neurology. 2005 Jun 28;64(12):2006-7
Authors: Gooch CL, Mitten DJ
Treat carpal tunnel syndrome PMID: 15985566 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
The importance of preoperative imaging in posttraumatic late carpal tunnel syndrome.
Plast Reconstr Surg. 2005 Jun;115(7):2157-8
Authors: Lakshman S, Veitch J
Treat carpal tunnel syndrome PMID: 15923890 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Diagnostic precision of ultrasonography in patients with carpal tunnel syndrome.
Am J Phys Med Rehabil. 2005 Jun;84(6):443-50
Authors: Keleş I, Karagülle Kendi AT, Aydin G, Zöğ SG, Orkun S
OBJECTIVE: To evaluate the diagnostic value of ultrasonography in patients with electrophysiologically confirmed carpal tunnel syndrome. DESIGN: A prospective ultrasonographic study of 35 wrists with electrophysiologically confirmed carpal tunnel syndrome and of 40 normal wrists. Receiver-operating-characteristics curves for the ultrasonographic measurements of median nerve were plotted to identify the most optimal cutoff values. RESULTS: The ultrasonographic measurements of median nerves were found to be increased significantly in patients with carpal tunnel syndrome when compared with controls, particularly in terms of cross-sectional area (P<0.001) and the bowing of the flexor retinaculum (P<0.01) but not in the flattening ratio (P>0.05). According to receiver-operating-characteristics curve results, the most optimal cutoff value for the cross-sectional area of the median nerve was obtained at the level of middle carpal tunnel, which was 9.3 mm, with a sensitivity of 80% and specificity of 77.5%. The optimal cutoff value for the bowing of the flexor retinaculum was 3.7 mm, with a sensitivity of 71.4% and specificity of 55%. No optimum cutoff value could be identified from the receiver-operating-characteristics curves for the flattening ratio of median nerve. CONCLUSION: Ultrasonographic examination of the median nerve seems to be a promising method in the diagnosis of carpal tunnel syndrome, evaluating the morphologic changes of the median nerve in patients with clinical signs and symptoms. Further studies with wider series are needed to confirm our preliminary results.
Treat carpal tunnel syndrome PMID: 15905658 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome.
Arch Phys Med Rehabil. 2005 Apr;86(4):609-18
Authors: Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML
OBJECTIVES: To develop a clinical prediction rule (CPR) and to assess the reliability and diagnostic accuracy of individual clinical examination items for the diagnosis of carpal tunnel syndrome (CTS). DESIGN: Prospective diagnostic test study with blind comparison to a reference criterion of a compatible clinical presentation and abnormal electrophysiologic findings. SETTING: Multicenter medical center and community hospital with patient referrals from ambulatory primary care and specialty practice settings. PARTICIPANTS: Eight-two consecutively referred patients (50% men; mean age, 45+/-12 y) with suspected cervical radiculopathy or CTS referred for electrophysiologic examination. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios. RESULTS: The CPR identified in this study consisted of 1 question (shaking hands for symptom relief), wrist-ratio index greater than .67, Symptom Severity Scale score greater than 1.9, reduced median sensory field of digit 1, and age greater than 45 years. The likelihood ratio for the CPR was 18.3 when all 5 tests were positive. Interrater reliability was acceptable for all but 2 clinical examination items. CONCLUSIONS: The CPR identified was more useful for the diagnosis of CTS than any single test item and resulted in posttest probability changes of up to 56%. Further investigation is required both to validate the test-item cluster and to improve point-estimate precision.
Treat carpal tunnel syndrome PMID: 15827908 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Effect of occupational keyboard typing on magnetic resonance imaging of the median nerve in subjects with and without symptoms of carpal tunnel syndrome.
Am J Phys Med Rehabil. 2005 Apr;84(4):258-66
Authors: Shafer-Crane GA, Meyer RA, Schlinger MC, Bennett DL, Robinson KK, Rechtien JJ
OBJECTIVE: To examine the effects of occupational keyboard typing on median nerve shape and T2 relaxation and on forearm muscle T2 in professional typists with and without symptoms of carpal tunnel syndrome. DESIGN: Based on the Levine Carpal Tunnel Syndrome Symptom Severity scale (LCTSS), 12 female professional typist volunteers were divided into asymptomatic (LCTSS < 1.3, n = 5) and symptomatic (LCTSS > 1.3, n = 7) groups. Magnetic resonance images were acquired from wrist and forearms of all subjects before, immediately after, and 8 hrs after 3 hrs of typing. Forearm muscle T2 and median nerve T2 cross-sectional area and long/short axis ratio were evaluated by blinded observers. RESULTS: There was no difference between groups in any measured variable before typing. Median nerve T2 increased and long/short axis ratio decreased in asymptomatic subjects after typing, but there were no significant changes in symptomatic subjects. T2 increased in finger flexor muscles after typing, but there was no difference in the pattern of muscle T2 changes between groups. CONCLUSION: In magnetic resonance images of the median nerve at the carpal tunnel, swelling and T2 increases from baseline are a normal response to typing and may be less likely to occur in subjects with symptoms of carpal tunnel syndrome.
Treat carpal tunnel syndrome PMID: 15785258 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Exacerbation of carpal tunnel syndrome under treatment with valdecoxib.
Anesth Analg. 2005 Apr;100(4):1215-6
Authors: Ruppen W, Schüpfer GK
Treat carpal tunnel syndrome PMID: 15781551 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
A prospective study of the long-term efficacy of local methyl prednisolone acetate injection in the management of mild carpal tunnel syndrome.
Rheumatology (Oxford). 2005 May;44(5):647-50
Authors: Agarwal V, Singh R, Sachdev A, Wiclaff , Shekhar S, Goel D
OBJECTIVE: Local glucocorticoid injections are used to treat carpal tunnel syndrome (CTS). However, this treatment is associated with frequent relapses. An important limitation of studies with higher relapse rates is that no attempt has been made to identify patients with mild or severe disease. We evaluated the efficacy of local glucocorticoid injection in patients with mild CTS. METHOD: Mild CTS was defined as intermittent symptoms without absence of sensations, muscle atrophy or weakness of the thenar muscles. Forty-eight patients with idiopathic mild CTS were evaluated before and 3 and 12 months after a single local injection of 40 mg methyl prednisolone acetate. Outcome was assessed by overall satisfaction on a 100 mm visual analogue scale, the Boston self-administered questionnaire for symptom severity and functional scores and improvement in the electrophysiological parameters. RESULTS: At 3 months, 93.7% of the patients reported marked improvement in their symptoms, with significant improvement in the mean values of the nerve conduction parameters distal motor latency at the wrist (DML) (P = 0.00001), distal sensory latency at mid-palm (DSL MP) (P = 0.014) and distal sensory latency at the wrist (DSL W) (P = 0.0003), and symptom severity (P = 4.96 x 10(-8)) and the functional scores (P = 3.56 x 10(-5)). Significant improvement was still present for DML (P = 1.39 x 10(-5)) at 12 months. Almost 50% of the patients achieved normalization in the electrophysiological study. At a median follow-up of 16 months, 79% patients continued to have improvement in their symptoms. Eight patients (16.6%) relapsed following the initial response. CONCLUSIONS: Local glucocorticoid injection results in long-term improvement in nerve conduction parameters, symptom severity and functional scores in patients with mild CTS.
Treat carpal tunnel syndrome PMID: 15743755 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
J Bone Joint Surg Br. 2005 Feb;87(2):196-200
Authors: Hobby JL, Venkatesh R, Motkur P
In a prospective study, we have evaluated the impact of psychological disturbance on symptoms, self-reported disability and the surgical outcome in a series of 110 patients with carpal tunnel syndrome. Self-reported severity of symptoms and disability were assessed using the patient evaluation measure and the Boston carpal tunnel questionnaire. Psychological distress was assessed using the hospital anxiety and depression scale. There was a significant association between psychological disturbance and the pre-operative symptoms and disability. However, there was no significant association between pre-operative psychological disturbance and the outcome of surgery at six months. We concluded that patients with carpal tunnel syndrome should not be denied surgery because of pre-operative psychological disturbance since it does not adversely affect the surgical outcome.
Treat carpal tunnel syndrome PMID: 15736742 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Consumer health information on the Internet about carpal tunnel syndrome: indicators of accuracy.
Am J Med. 2005 Feb;118(2):168-74
Authors: Frické M, Fallis D, Jones M, Luszko GM
PURPOSE: To identify indicators of accuracy for consumer health information on the Internet. METHODS: Several popular search engines were used to find websites on carpal tunnel syndrome. The accuracy and completeness of these sites were determined by orthopedic surgeons. It also was noted whether proposed indicators of accuracy were present. The correlation between proposed indicators of accuracy and the actual accuracy of the sites was calculated. RESULTS: A total of 116 websites and 29 candidate indicators were examined. A high Google toolbar rating of the main page of a site, many inlinks to the main page of a site, and an unbiased presentation of information on carpal tunnel syndrome were considered genuine indicators of accuracy. Many proposed indicators taken from published guidelines did not indicate accuracy (e.g., the author or sponsor having medical credentials). CONCLUSION: There are genuine indicators of the accuracy of health information on the Internet. Determining these indicators, and informing providers and consumers of health information about them, would be useful for public health care. Published guidelines have proposed many indicators that are obvious to unaided observation by the consumer. However, indicators that make use of the invisible link structure of the Internet are more reliable guides to accurate information on carpal tunnel syndrome.
Treat carpal tunnel syndrome PMID: 15694903 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial.
Arthritis Rheum. 2005 Feb;52(2):612-9
Authors: Ly-Pen D, Andréu JL, de Blas G, Sánchez-Olaso A, Millán I
OBJECTIVE: Optimal treatment of carpal tunnel syndrome (CTS) has not been established. This study compared the effects of local steroid injection versus surgical decompression in new-onset CTS of at least 3 months' duration. METHODS: In a 1-year, prospective, randomized, open, controlled clinical trial, we studied the effects of surgical decompression versus local steroid injection in 163 wrists with a clinical and neurophysiologic diagnosis of CTS. Clinical assessments were done at baseline and at 3, 6, and 12 months after treatment. The primary end point was the percentage of wrists that reached a >or=20% improvement in the visual analog scale score for nocturnal paresthesias at 3 months of followup. Statistical analysis was done by Student's t-test for continuous variables and by chi-square test for categorical variables. Analyses were performed on an intent-to-treat basis. P values less than 0.05 were considered statistically significant. RESULTS: Both treatment groups had comparable severity of CTS at baseline. Eighty wrists were randomly assigned to the surgery group and 83 wrists to the local steroid injection group. In the intent-to-treat analysis, at 3 months of followup, 94.0% of the wrists in the steroid injection group versus 75.0% in the surgery group reached a 20% response for nocturnal paresthesias (P = 0.001). At 6 and 12 months, the percentages of responders were 85.5% versus 76.3% (P = 0.163) and 69.9% versus 75.0% (P = 0.488), for local steroid injection and surgical decompression, respectively. CONCLUSION: Over the short term, local steroid injection is better than surgical decompression for the symptomatic relief of CTS. At 1 year, local steroid injection is as effective as surgical decompression for the symptomatic relief of CTS.
Treat carpal tunnel syndrome PMID: 15692981 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Evaluation of iontophoresis and local corticosteroid injection in the treatment of carpal tunnel syndrome.
Am J Phys Med Rehabil. 2005 Feb;84(2):92-6
Authors: Gökoğlu F, Fndkoğlu G, Yorgancoğlu ZR, Okumuş M, Ceceli E, Kocaoğlu S
OBJECTIVE: The aim of this study was to compare the efficacy of local corticosteroid injection with iontophoresis of corticosteroids in the treatment of carpal tunnel syndrome. DESIGN: This study was a prospective, randomized, unblinded clinical trial with follow-up at 2 and 8 wks. Thirty patients (48 median nerves) with clinical and electrophysiologic evidence of carpal tunnel syndrome were included in the study. Patients were evaluated by use of clinical variables, a functional status scale, a symptom severity scale, and visual analog scale. A total of 48 median nerves were randomly assigned to one of two groups; group 1 received 40 mg of methylprednisolone acetate injected locally in the carpal tunnel, and group 2 received iontophoresis of dexamethasone sodium phosphate. Clinical variables and scales were evaluated at regular intervals: at the beginning and at the end of therapy in the second and eighth week. RESULTS: Twenty-seven patients (90%) were women and three patients (10%) were men. The mean age of patients was 48.0 +/- 8.2 (range, 29-61) yrs. There was a statistically significant improvement in the clinical examination variables, visual analog scale, symptom severity scale, and functional status scale scores of the patients in both of the treatment groups posttreatment (at 2 and 8 wks) compared with baseline (P < 0.05). However, there was a statistically significant difference between the values of the two group. A significant difference in mean symptom severity scale, functional status scale, and visual analog scale scores was found in second week and eighth week in the injection group compared with iontophoresis. CONCLUSION: Our study comparing a standardized treatment protocol for incorporating local corticosteroid injection and iontophoresis of dexamethasone sodium phosphate in carpal tunnel syndrome revealed success of both iontophoresis of dexamethasone sodium phosphate and injection of corticosteroids, but symptom relief was greater at 2 and 8 wks with injection of corticosteroids.
Treat carpal tunnel syndrome PMID: 15668556 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Diagnostic value of sonography in patients with suspected carpal tunnel syndrome: a prospective study.
Arthritis Rheum. 2005 Jan;52(1):304-11
Authors: Ziswiler HR, Reichenbach S, Vögelin E, Bachmann LM, Villiger PM, Jüni P
OBJECTIVE: To determine the diagnostic value of sonography in patients with suspected carpal tunnel syndrome (CTS). METHODS: We conducted a prospective study of 110 wrists in 74 consecutive patients with suspected CTS who had been referred to a tertiary care center. We determined the largest cross-sectional area of the median nerve at the carpal tunnel. Because of the lack of a universally accepted reference standard, we first examined the association of sonography with nerve conduction. Then, we compared sonography with a reference standard based on the combination of nerve conduction studies and signs and symptoms. Sonography and reference standard tests were performed independently and interpreted under blinded conditions. Based on a fitted receiver operating characteristic curve, we estimated likelihood ratios (LRs) and posttest probabilities for different cutoffs. RESULTS: There was a high concordance between sonography and nerve conduction. Based on the combined reference standard, a cutoff of 10 mm(2) resulted in approximately equal sensitivity and specificity, but only moderate LRs. A cutoff of <8 mm(2) had satisfactory power to rule out CTS: the fitted-negative LR was 0.13. Conversely, a cutoff of > or =12 mm(2) had excellent power to rule in CTS, with a fitted-positive LR of 19.9. For nerves > or =12 mm(2) and a pretest probability of 70% expected in patients with suspected CTS in tertiary care, we found a posttest probability of CTS of 98%. CONCLUSION: Depending on setting and purpose, different cutoff values for the largest cross-sectional area may be used to accurately rule in or rule out CTS. Using sonography as a first-line test may cost-effectively reduce the number of nerve conduction studies in patients with suspected CTS. A large-scale, randomized controlled trial is required to determine the effects of sonography on clinical outcomes, the number of nerve conduction studies performed, and the total cost.
Treat carpal tunnel syndrome PMID: 15641050 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Sensitivity, specificity, and variability of nerve conduction velocity measurements in carpal tunnel syndrome.
Arch Phys Med Rehabil. 2005 Jan;86(1):12-6
Authors: Lew HL, Date ES, Pan SS, Wu P, Ware PF, Kingery WS
OBJECTIVE: To explore the diagnostic values of 8 commonly used electrodiagnostic techniques for measuring median nerve conduction velocity (NCV) in carpal tunnel syndrome (CTS). DESIGN: Sensitivity and specificity analyses. SETTING: A hospital-based electrodiagnostic laboratory. PARTICIPANTS: Forty-four normal hands and 136 symptomatic hands. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: (1) Long-segment studies: antidromic wrist-to-digit sensory NCV without subtraction, (2) short-segment studies: transcarpal palm-to-wrist mixed NCV without subtraction, and (3) 2 segment studies: antidromic transcarpal sensory NCV with subtraction (differential calculation from wrist-to-digit and palm-to-digit segments). Both onset and peak latency values were obtained for calculating the NCV. Sensitivity, specificity, and coefficient of variance were calculated for each NCV study. RESULTS: The short-segment, onset latency-based transcarpal mixed NCV yielded the highest sensitivity (75%). CONCLUSIONS: Results from measurement of a single, short-nerve segment tended to be superior to results obtained by either long-segment studies or differential subtraction between 2 segments of the same nerve in the electrodiagnosis of CTS. Explanations for our results are offered from both electrophysiologic and statistical perspectives.
Treat carpal tunnel syndrome PMID: 15640982 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Randomized controlled trial of nocturnal splinting for active workers with symptoms of carpal tunnel syndrome.
Arch Phys Med Rehabil. 2005 Jan;86(1):1-7
Authors: Werner RA, Franzblau A, Gell N
OBJECTIVES: To determine whether nocturnal splinting of workers identified through active surveillance with symptoms consistent with carpal tunnel syndrome (CTS) would improve symptoms and median nerve function as well as impact medical care. DESIGN: Randomized controlled trial. SETTING: A Midwestern auto assembly plant. PARTICIPANTS: Active workers with symptoms suggestive of CTS based on a hand diagram. INTERVENTION: The treatment group received customized wrist splints, which were worn at night for 6 weeks; the control group received ergonomic education alone. MAIN OUTCOME MEASURES: Change in wrist, hand, and/or finger discomfort, carpal tunnel symptom severity index, median sensory nerve function, and the percentage of subjects who had carpal tunnel release surgery. RESULTS: The splinted group, unlike the controls, had a significant reduction in wrist, hand, and/or finger discomfort and a similar trend in the Levine carpal tunnel symptom severity index, which was maintained at 12 months. A secondary analysis showed that more median nerve impairment at baseline was associated with less clinical improvement among controls but not among the splinted group. CONCLUSIONS: Workers identified with CTS symptoms in an active symptom surveillance tended to benefit from a 6-week nocturnal splinting trial, and the benefits were still evident at the 1-year follow-up. The splinted group improved in terms of hand discomfort regardless of the degree of median nerve impairment, whereas the controls showed improvement only among subjects with normal median nerve function. Results suggest that a short course of nocturnal splinting may reduce wrist, hand, and/or finger discomfort among active workers with symptoms consistent with CTS.
Treat carpal tunnel syndrome PMID: 15640980 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Synovitis induced by alendronic acid can present as acute carpal tunnel syndrome.
BMJ. 2005 Jan 8;330(7482):74
Authors: Jones DG, Savage R, Highton J
Treat carpal tunnel syndrome PMID: 15637369 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Nonsurgical treatment is effective for carpal tunnel syndrome.
J Fam Pract. 2004 Sep;53(9):685
Authors:
Treat carpal tunnel syndrome PMID: 15353153 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Poor outcome for neural surgery (epineurotomy or neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone: a meta-analysis of global outcomes.
Plast Reconstr Surg. 2004 Sep 1;114(3):828-30; author reply 830
Authors: Margic K
Treat carpal tunnel syndrome PMID: 15318085 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
A comparison of flexor tenosynovectomy, open carpal tunnel release, and open carpal tunnel release with flexor tenosynovectomy in the treatment of carpal tunnel syndrome.
Plast Reconstr Surg. 2004 Jun;113(7):2020-9
Authors: Ketchum LD
The purpose of this study was to identify the advantages and disadvantages of performing a flexor tenosynovectomy without dividing the transverse carpal ligament, an open carpal tunnel release, and an open carpal tunnel release with flexor tenosynovectomy in the treatment of carpal tunnel syndrome. From 1990 to 1998, a retrospective study was done in which a flexor tenosynovectomy was performed in 133 patients without division of the transverse carpal ligament and compared with 68 patients who had an open carpal tunnel release and 75 patients who had an open carpal tunnel release and flexor tenosynovectomy. Patients were followed up for an average period of 30 weeks with history and physical findings and nerve conduction velocities and for an average period of 2.6 years with telephone interviews. There was a 2.3 percent incidence of pillar pain in the flexor tenosynovectomy group, which may explain the earlier return to their regular jobs at an average time of 9.9 weeks, compared with 10.7 weeks for the carpal tunnel release group and 12.0 weeks for the carpal tunnel release/flexor tenosynovectomy group. The latter two groups had an incidence of pillar pain of 12.1 percent and 25.3 percent, respectively. Postoperative grip strength was statistically significantly improved in the flexor tenosynovectomy group compared with the other two groups, where adjustments were made for sex and preoperative grip strengths with standard error of adjusted means. In the flexor tenosynovectomy group, 20.6 percent of patients had a previous open or endoscopic carpal tunnel release with recurrent carpal tunnel syndrome, compared with 5.2 percent in the open carpal tunnel release group and 21.6 percent in the open carpal tunnel release with flexor tenosynovectomy group. Excisional biopsies of flexor tenosynovium in the flexor tenosynovectomy, open carpal tunnel release, and open carpal tunnel release with flexor tenosynovectomy groups revealed an incidence of fibrosis in 89.2 percent, 88.9 percent, and 87.7 percent of specimens, respectively. Edema was a frequent finding, but an active inflammatory response was seldom seen. The findings in this study indicate that because of a significant decrease in pillar pain, a flexor tenosynovectomy in the treatment of carpal tunnel syndrome would likely benefit workers who use the palm of the hand in heavy manual or highly repetitive work by allowing them to return to regular duty sooner.
Treat carpal tunnel syndrome PMID: 15253192 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
A histological and immunohistochemical study of the subsynovial connective tissue in idiopathic carpal tunnel syndrome.
J Bone Joint Surg Am. 2004 Jul;86-A(7):1458-66
Authors: Ettema AM, Amadio PC, Zhao C, Wold LE, An KN
BACKGROUND: The most common histological finding in carpal tunnel syndrome is noninflammatory synovial fibrosis. The accumulated effect of minor injuries is believed to be an important etiologic factor in some cases of carpal tunnel syndrome. We sought evidence of such injuries in the synovial tissue of patients with carpal tunnel syndrome and in cadaver controls. METHODS: We compared synovial specimens from thirty patients who had idiopathic carpal tunnel syndrome with specimens from a control group of ten fresh-frozen cadavers of individuals who had not had an antemortem diagnosis of carpal tunnel syndrome and who met the same exclusion criteria. Analysis included histological and immunohistochemical examination for the distribution of collagen types I, II, III, and VI and transforming growth factor-beta (TGF-beta) RI, RII, and RIII. RESULTS: Histological examination showed a marked increase in fibroblast density, collagen fiber size, and vascular proliferation in the specimens from the patients compared with the control specimens (p < 0.001). Collagen types I and II were not found in the synovium of either the patients or the controls, but collagen type VI was a major component of both. Collagen type-III fibers were more abundant in the patients than in the controls (p < 0.001). Expression of TGF-beta RI was found in the endothelial cells and fibroblasts in the patient and control specimens, with a marked increase in expression in the fibroblasts of the patients compared with that in the control tissue (p < 0.001). CONCLUSIONS: These findings are similar to those after injury to skin, tendon, and ligament and suggest that patients with idiopathic carpal tunnel syndrome may have sustained an injury to the subsynovial connective tissue.
Treat carpal tunnel syndrome PMID: 15252093 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Carpal tunnel syndrome: diagnostic usefulness of sonography.
Radiology. 2004 Jul;232(1):93-9
Authors: Wong SM, Griffith JF, Hui AC, Lo SK, Fu M, Wong KS
PURPOSE: To prospectively evaluate accuracy of sonography for diagnosis of carpal tunnel syndrome (CTS) in patients clinically suspected of having the disease in one or both hands. MATERIALS AND METHODS: A prospective cohort of 133 patients suspected of having CTS were referred to a teaching hospital between October 2001 and June 2002 for electrodiagnostic study. One hundred twenty patients (98 women, 22 men; mean age, 49 years; range, 19-83 years) underwent sonography within 1 week after electrodiagnostic study. Radiologist was blinded to electrodiagnostic study results. Seventy-five patients had bilateral symptoms; 23 patients, right-hand symptoms; and 22 patients, left-hand symptoms (total, 195 symptomatic hands). Cross-sectional area of median nerve was measured at three levels: immediately proximal to carpal tunnel inlet, at carpal tunnel inlet, and at carpal tunnel outlet. Flexor retinaculum was used as a landmark to margins of carpal tunnel. Optimal threshold levels (determined with classification and regression tree analysis) for areas proximal to and at tunnel inlet and at tunnel outlet were used to discriminate between patients with and patients without disease. Sensitivity, specificity, and false-positive and false-negative rates were derived on the basis of final diagnosis, which was determined with clinical history and electrodiagnostic study results as reference standard. RESULTS: For right hands, sonography had sensitivity of 94% (66 of 70); specificity, 65% (17 of 26); false-positive rate, 12% (nine of 75); and false-negative rate, 19% (four of 21) (cutoff, 0.09 cm(2) proximal to tunnel inlet and 0.12 cm(2) at tunnel outlet). For left hands, sensitivity was 83% (53 of 64); specificity, 73% (24 of 33); false-positive rate, 15% (nine of 62); and false-negative rate, 31% (11 of 35) (cutoff, 0.10 cm(2) proximal to tunnel inlet). CONCLUSION: Sonography is comparable to electrodiagnostic study in diagnosis of CTS and should be considered as initial test of choice for patients suspected of having CTS.
Treat carpal tunnel syndrome PMID: 15155897 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome.
Am J Phys Med Rehabil. 2004 May;83(5):363-7
Authors: Hansen PA, Micklesen P, Robinson LR
OBJECTIVE: To determine the utility of the flick maneuver (flicking motion of hands and wrists when most symptomatic) in the clinical evaluation of carpal tunnel syndrome (CTS). DESIGN: Review of standardized data collection on 142 subjects referred for electrodiagnostic evaluation of possible CTS at a university hospital electrodiagnostic clinic. Subjects were first clinically evaluated with the flick, Phalen, and Tinel maneuvers. Subsequently, they all underwent nerve conduction studies. Electrodiagnostic results were used as the gold standard for patient group assignments. Sensitivities, specificities, and predictive values for individual and combined clinical tests were determined. McNemar chi square values were calculated to determine whether one test identified more patients with CTS. The sensitivities of clinical maneuvers were also evaluated in relation to electrodiagnostic severity of CTS. RESULTS: Of the 142 subjects, 67% had CTS. The sensitivities of the flick, Tinel, and Phalen signs were 37%, 27%, and 34%, respectively. False-positive results ranged from 8% (Tinel) to 26% (flick and Phalen). Positive predictive values for the flick, Tinel, and Phalen maneuvers were 74%, 87%, and 73%, respectively, and negative predictive values were 37%, 39%, and 35%. McNemar chi square results revealed that the flick maneuver detected more subjects with CTS than the Tinel sign. With increasing electrodiagnostic severity, the sensitivity of all clinical tests tended to improve slightly. CONCLUSION: The flick sign is of limited clinical utility in diagnosing CTS, with low sensitivity and specificity.
Treat carpal tunnel syndrome PMID: 15100625 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Ultrasonography versus nerve conduction study in patients with carpal tunnel syndrome: substantive or complementary tests?
Rheumatology (Oxford). 2004 Jul;43(7):887-95
Authors: El Miedany YM, Aty SA, Ashour S
OBJECTIVE: Our aim is to assess the optimal discriminatory sonographic criteria and relevant threshold values in patients with carpal tunnel syndrome (CTS) and to evaluate quantitative ultrasonography (US) as a tool for diagnosis and treatment of patients suffering from carpal tunnel syndrome in comparison with electrophysiological study. METHODS: Seventy-eight patients with CTS and 78 asymptomatic controls were assessed and underwent ultrasonography of the wrists. All patients and controls completed a self-administered questionnaire. Electrophysiological testing was done for all patients and control subjects. Data from the patient and the control groups were compared to determine the diagnostic relations in patients with CTS and the grade of severity. RESULTS: There was a high degree of correlation between the conduction abnormalities of the median nerve as detected by electrodiagnostic tests, self-administered assessment and the measurement of the cross-sectional area of the nerve by US (P<0.05). Various levels of disease severity could also be illustrated by US, giving confident results for diagnosis, treatment planning and following the patients with CTS. In 16 patients (17%) tenosynovitis/localized swelling in the tendons in the carpal tunnel was the primary cause of CTS. A cut-off point of 10 mm(2) for the mean cross-sectional area of the median nerve was found to be the upper limit for normal values. Based on the results of this study, an algorithm for evaluation and management of CTS has been suggested. CONCLUSION: High-frequency US examination of the median nerve and measurement of its cross-sectional area should be strongly considered as a new alternative diagnostic modality for the evaluation of CTS. In addition to being of high diagnostic accuracy it is able to define the cause of nerve compression and aids treatment planning; US also provides a reliable method for following the response to therapy.
Treat carpal tunnel syndrome PMID: 15100417 [PubMed - indexed for MEDLINE (Treat carpal tunnel syndrome)]
Arnold-Chiari malformation with syrinx presenting as carpal tunnel syndrome: a case report.
Arch Phys Med Rehabil. 2004 Jan;85(1):158-61
Authors: Ziadeh MJ, Richardson JK
A 26-year-old administrative assistant presented with 3 years of left-hand dysesthesia involving primarily the first 3 digits. Her symptoms increased at night and with keyboard use. Through 12 visits to primary and specialty care physicians over 3 years, she experienced minimal improvement with splints and moderate improvement with gabapentin.
