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Latest Research on Carpal Tunnel
     
Ulster Med J. 2008 Jan;77(1):22-4.
Open carpal tunnel release--still a safe and effective operation.
Badger SA, O'Donnell ME, Sherigar JM, Connolly P, Spence RA.
Department of Surgery, Level 2, Belfast City Hospital Lisburn Road, Belfast BT9 7AB. stephenbadger@btinternet.com

BACKGROUND: Carpal tunnel syndrome is a common cause of neurological symptomatology. Surgical decompression remains the treatment of choice in patients not responding to conservative therapies. The aim of this study was to assess the effectiveness of standard open decompression by analysis of symptomatic and functional improvement and to assess whether a general surgeon can still perform this operation safely. PATIENTS AND METHODS: Patients undergoing standard open carpal tunnel release by a single general surgeon were recruited. A self-administered Boston questionnaire was used to assess symptom severity and functional status pre- and post-surgical intervention. RESULTS: Forty-seven patients (51 hands) underwent carpal tunnel release and 32 patients completed the questionnaire. 88% had a significant reduction in the symptom severity score, while improvement in function status score was achieved in 79% of patients. Mean symptom severity score improved from 3.41 points preoperatively to 1.85 (p < 0.0001) points at the last follow up examination, while the mean function status score improved from 2.73 to 1.99 points (p < 0.0001). Outcome was poor in six patients with slight worsening of either symptom or function status score. Three patients were treated conservatively for minor wound infection without long-term sequelae. DISCUSSION: Standard open carpal tunnel release still provides efficacious symptomatic relief with a low risk of associated complications when performed by a general surgeon.

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Ulster Med J. 2008 Jan;77(1):6-17.
Carpal tunnel syndrome.
Aroori S, Spence RA.
Department of Surgery, Level-2, Belfast HSC Trust, Lisburn Road, Belfast BT9 7AB, United Kingdom.

Carpal tunnel syndrome is one of the most common peripheral neuropathies. It affects mainly middle aged women. In the majority of patients the exact cause and pathogenesis of CTS is unclear. Although several occupations have been linked to increased incidence and prevalence of CTS the evidence is not clear. Occupational CTS is uncommon and it is essential to exclude all other causes particularly the intrinsic factors such as obesity before attributing it to occupation. The risk of CTS is high in occupations involving exposure to high pressure, high force, repetitive work, and vibrating tools. The classic symptoms of CTS include nocturnal pain associated with tingling and numbness in the distribution of median nerve in the hand. There are several physical examination tests that will help in the diagnosis of CTS but none of these tests are diagnostic on their own. The gold standard test is nerve conduction studies. However, they are also associated with false positive and false negative results. The diagnosis of CTS should be based on history, physical examination and results of electrophysiological studies. The patient with mild symptoms of CTS can be managed with conservative treatment, particularly local injection of steroids. However, in moderate to severe cases, surgery is the only treatment that provides cure. The basic principle of surgery is to increase the volume of the carpal tunnel by dividing transverse carpal ligament to release the pressure on the median nerve. Apart from early recovery and return to work there is no significant difference in terms of early and late complications and long-term pain relief between endoscopic and open carpal tunnel surgery.

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Ned Tijdschr Geneeskd. 2008 Jan 12;152(2):76-81.
[Guideline 'Diagnosis and treatment of carpal tunnel syndrome']
[Article in Dutch]
de Krom MC, van Croonenborg JJ, Blaauw G, Scholten RJ, Spaans F.
Academisch Ziekenhuis Maastricht, Maastricht.

Carpal tunnel syndrome (CTS) is the most frequently encountered peripheral nerve entrapment: about 10% of adult women and less than 1% of adult men in the Netherlands have a clinically and electrophysiologically confirmed CTS. --All medical and paramedical disciplines involved in the diagnosis and treatment of CTS in the Netherlands contributed to the development of a guideline for the diagnosis and treatment ofCTS. --Clinical diagnosis of CTS is based on a history of nocturnal pins and needles, numbeness and/or pain in the median nerve innervated area of the fingers and hand, which often causes the patient to awake. --Provocative tests do not contribute to the clinical diagnosis of CTS. --If invasive therapy is considered, such as corticosteroid injection or surgery, the clinical diagnosis must be confirmed by abnormal findings in electrophysiological tests. --Ultrasound or MRI of the wrist may be of diagnostic value when structural abnormalities in the carpal tunnel are suspected. Given the special expertise needed for ultrasound testing and the limited availability of MRI for CTS diagnostic purposes, these methods are not the first preference. --Depending on the degree of impact on daily functioning, treatment for CTS may be expectative, conservative (wrist splint or local steroid injections) or surgical (endoscopic or open techniques). --If CTS does not restrict daily functioning, adjustment of the working conditions will do. --Furthermore measures aimed at CTS prevention and treatment of an already existing work-related CTS are discussed.

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Minim Invasive Neurosurg. 2007 Dec;50(6):328-34.
Carpal tunnel syndrome in young adults--an ultrasonographic and neurophysiological study.
Polykandriotis E, Premm W, Horch RE.
1Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany.

BACKGROUND: The carpal tunnel syndrome (CTS) is by far the most frequent compression neuropathy and encompasses 45% of all non-traumatic nerve lesions. Women are affected twice as often as men and manifestation usually occurs over the age of 30; 76% of all patients become symptomatic between the age of 40-70 years. In young adults typical diagnostic clues suggestive of a CTS, may be absent leading to misdiagnosis and late treatment. PATIENTS AND METHODS: 30 patients suffering from CTS were subdivided in 2 groups according to age. Patients under the age of 35 were allocated in group A whereas patients over 35 years old were included in group B. The two groups were compared to each other in terms of demographics, clinical signs, electrodiagnosis and ultrasonography of the carpal tunnel. All patients were subjected to a decompression procedure of the median nerve and postoperative alleviation of the symptoms was considered as confirmation of the presence of a CTS. Two characteristic clinical cases of young adults suffering from CTS are demonstrated. RESULTS: The female to male ratio was higher in group A (7:1) than in group B (3:1). Only two (25%) of the patients in group A had a positive Tinel sign but in 7 patients (87.5%) the Phalen test could be readily evoked. In group B a Tinel sign was present in 45% whereas a positive Phalen test was present in 86%. A positive Tinel sign was associated with a distal motor latency beyond 4 ms in the two patients from group A. A distal motor latency was present in 95.2% of the patients in group B. In ultrasound there was an average decrease of 0.557 mm in the thickness of the median nerve throughout its course in the carpal tunnel in group B. In group A, ultrasonography revealed no significant changes in nerve diameter. DISCUSSION: The value of electrophysiological studies as a diagnostic tool in CTS still remains controversial. In young adults phenomena leading to impaired nerve conduction like axonal demyelination of the median nerve might occur later due to a higher regenerative potential. However, symptomatic patients may be strongly hindered in their everyday activities and occupation and should be readily referred to a hand specialist in spite of a negative work-up.

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Plast Reconstr Surg. 2007 Dec;120(7):1911-21.
A 12-year experience using the brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
Hankins CL, Brown MG, Lopez RA, Lee AK, Dang J, Harper RD.
Houston Hand House and the Hand Center, Texas 77292, USA.

BACKGROUND: Compared with the open technique, endoscopic carpal tunnel release has a shorter postoperative recovery period but has been associated with an increased risk of iatrogenic injury. Because of morbidity of the open method, including painful scars, pillar pain, tendon adhesions, scar entrapment of the median nerve, chronic regional pain syndrome, and a longer postoperative recovery period, many patients have been treated nonoperatively to circumvent or forestall surgery, resulting in unrelieved median nerve compression and an increased risk of permanent nerve injury. METHODS: Inclusion criteria included a diagnosis of carpal tunnel syndrome based on history and physical examination and electrodiagnostic studies; failure of a short trial of conservative therapy; and advanced disease as evidenced by sensory, motor, or atrophic changes in the median nerve distribution. Exclusion criteria included prior surgery, wrist extension of greater than 40 degrees, mass within the carpal tunnel, Guyon's syndrome, and bony carpal tunnel abnormalities. Patients meeting these criteria were treated by the Brown two-portal endoscopic technique. RESULTS: A total of 14,722 patients were treated with the Brown endoscopic procedure. Eleven patients (0.07 percent) required conversion to an open procedure. There was one iatrogenic injury. Postoperative results were inversely related to the severity of the preoperative electrodiagnostic studies and the duration of symptoms regardless of the method of nonoperative treatment given. CONCLUSIONS: Operative decompression should be carried out promptly if symptoms have been present for 2 months or longer, as the occurrence of permanent nerve damage has been noted within this time frame. The authors advocate use of the two-portal endoscopic technique as previously described by Brown et al. for this purpose.

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Pain Physician. 2007 Nov;10(6):765-70.
Pulsed radiofrequency of the median nerve under ultrasound guidance.
Haider N, Mekasha D, Chiravuri S, Wasserman R.
Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109-0048, USA. nhaider@med.umich.edu

Neuropathy of the median nerve within the carpal tunnel (carpal tunnel syndrome) has an age adjusted incidence of 105 cases per 100,000 person years. Treatment of carpal tunnel syndrome ranges from conservative management with medication and exercise to surgical release of the median nerve. Conservative treatment accounts for a significant portion of resources utilized and includes splinting, nerve gliding, ultrasound, and carpal bone mobilization. Recurrent symptoms of carpal tunnel syndrome have been shown to occur in 0% to 19% of patients following carpal tunnel release, with up to 12% requiring re-exploration. Prognosis for re-exploration is not as good as for primary carpal tunnel release, with a high recurrence rate in some populations. Ultrasound has seen increasing use in regional anesthesia and has been shown to improve the quality of regional anesthetic blocks. Pulsed radiofrequency was developed with the goal of providing reduction in pain from the use of electrical fields in the absence of neural injury. The use of ultrasound guidance for positioning radiofrequency probes over peripheral nerves has not been reported. This case report describes the use of ultrasound guided pulsed radiofrequency in the treatment of recurrent carpal tunnel syndrome. Following revision carpal tunnel surgery, the patient in this report was unable to obtain relief of pain in either hand with medication therapy alone. After a successful diagnostic median nerve block at the cubital fossa, pulsed radiofrequency of the median nerve was performed on the left side at the cubital fossa, under ultrasound guidance. Radiofrequency probe adjustment around the nerve was conducted under live ultrasound guidance and multiple pulsed treatments were applied at anatomically distinct sites over the nerve. A 70% reduction in pain was reported over the follow up period of 12 weeks.

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Arthritis Rheum. 2007 Nov;56(11):3620-5.
Carpal tunnel syndrome and keyboard use at work: a population-based study.
Atroshi I, Gummesson C, Ornstein E, Johnsson R, Ranstam J.
Hässleholm Hospital, Hässleholm, Sweden. Isam.Atroshi@skane.se

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.

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Arch Phys Med Rehabil. 2007 Nov;88(11):1429-35.
Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.
Brininger TL, Rogers JC, Holm MB, Baker NA, Li ZM, Goitz RJ.
Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA.

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.

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Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003905.
Surgical treatment options for carpal tunnel syndrome.
Scholten RJ, Mink van der Molen A, Uitdehaag BM, Bouter LM, de Vet HC.
Academic Medical Center, Dutch Cochrane Centre, Room J1B - 108 - 1, P.O. Box 22700, Amsterdam, Netherlands, 1100 DE. r.j.scholten@amc.uva.nl

BACKGROUND: Carpal tunnel syndrome is a common disorder for which several surgical treatment options are available. OBJECTIVES: To compare the efficacy of the various surgical techniques in relieving symptoms and promoting return to work or activities of daily living and to compare the occurrence of side-effects and complications in patients suffering from carpal tunnel syndrome. SEARCH STRATEGY: We updated the searches in 2006. We conducted computer-aided searches of the Cochrane Neuromuscular Disease Group Trials Register (searched in June 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (January 1966 to June 2006), EMBASE (January 1980 to June 2006) and also tracked references in bibliographies. SELECTION CRITERIA: Randomised controlled trials comparing various surgical techniques for the treatment of carpal tunnel syndrome. DATA COLLECTION AND ANALYSIS: Two review authors performed study selection, assessment of methodological quality and data extraction independently of each other. MAIN RESULTS: Thirty-three studies were included in the review of which 10 were newly identified in this update. The methodological quality of the trials ranged from fair to good; however, the use of allocation concealment was mentioned explicitly in only seven trials. Many studies failed to present the results in sufficient detail to enable statistical pooling. Pooling was also impeded by the vast variety of outcome measures that were applied in the various studies. None of the existing alternatives to standard open carpal tunnel release offered significantly better relief from symptoms in the short- or long-term. In three studies with a total of 294 participants, endoscopic carpal tunnel release resulted in earlier return to work or activities of daily living than open carpal tunnel release, with a weighted mean difference of -6 days (95% CI -9 to -3 days). AUTHORS' CONCLUSIONS: There is no strong evidence supporting the need for replacement of standard open carpal tunnel release by existing alternative surgical procedures for the treatment of carpal tunnel syndrome. The decision to apply endoscopic carpal tunnel release instead of open carpal tunnel release seems to be guided by the surgeon's and patient's preferences.

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Electromyogr Clin Neurophysiol. 2007 Sep;47(6):259-71.
Long term follow-up of carpal tunnel syndrome during pregnancy: a cohort study and review of the literature.
Mondelli M, Rossi S, Monti E, Aprile I, Caliandro P, Pazzaglia C, Romano C, Padua L.
EMG Service ASL7, Siena, Italy. m.mondelli@usl7.toscana.it

INTRODUCTION: Carpal tunnel syndrome (CTS) occurring during pregnancy is considered to have a short and benign course and very few cases required surgery, however there is no information in literature on long term follow-up. The aim of this study was a systematic review of the literature and to report 3-year follow-up after delivery in a sample of pregnant women with CTS. PATIENTS AND METHODS: We enrolled 45 consecutive pregnant women with CTS (mean age 32 years). Diagnosis was based on clinical and neurographic findings. Clinical and electrophysiological severity of CTS were scored according to an ordinal scale and the self-administered Boston questionnaires on symptoms (BQ-SYMPT) and functional status (BQ-FUNCT) of the hand during pregnancy and one-year after delivery. Symptoms were evaluated again by BQ over the telephone three years after delivery. RESULTS: At one-year follow-up BQ-SYMPT and BQ-FUNCT scores improved in 40% of women, did not change in 46.7% and 55.6% and worsened in 13.3% and 4.4%, respectively. Clinical severity was stage 0 (i. e. without symptoms) in 26.7% of women, improved in 6.7%, unchanged in 60% and worse in 6.7%. Electrophysiological severity was stage 0 (i.e. no delay in median nerve conduction) in 17.8%, improved in 20%, unchanged in 57.8% and worse in 4.4%. Only one woman underwent surgery (5 months after delivery), three were treated with local steroid injection before delivery and 18 used a splint, 8 of whom continued to do so periodically after one year. At 3-year follow-up 51% were symptom-free and 49% had anomalous ( > 1) BQ scores, but mean BQ scores improved with respect to those at baseline and one-year follow-up. CONCLUSION: A Pubmed search identified 20 papers in which therapy and follow-up could be deduced. Almost all reported a short follow-up with disappearance of symptoms. Our study confirms that pregnancy-related CTS has a benign course: improvement of symptoms was evident at one- and 3-year follow-up, but about half the women still complained of symptoms 3 years after delivery. Only one woman underwent surgery and 11% still sometimes wore a splint at night. Despite improvement of symptoms, distal sensory conduction velocity of the median nerve improved but remained delayed in 84% of women one year after delivery.

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Muscle Nerve. 2007 Aug;36(2):167-71.
Treatment of carpal tunnel syndrome.
Bland JD.
Department of Clinical Neurophysiology, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent CT1 3NG, UK.

Fifty years after its widespread recognition, a significant minority of patients with carpal tunnel syndrome continue to experience poor outcomes from treatment. Much current treatment is supported by an inadequate or nonexistent evidence base. Surgical decompression, often considered the definitive solution, gives excellent results in only 75% of cases in ordinary practice and leaves 8% of patients worse than previously. The only other interventions that are clearly of benefit are neutral-angle wrist splinting, with a success rate of 37%, and steroids, which are better given by local injection than as oral treatment. The initial response rate to injection is 70% but there are frequent relapses. Nevertheless, these conservative treatments have a negligible incidence of serious complications and should be used more widely until surgical failures can be reduced to similar levels. Muscle Nerve, 2007.

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Postgrad Med J. 2007 Jul;83(981):498-501.
Primary care management of patients with carpal tunnel syndrome referred to surgeons: are non-operative interventions effectively utilised?
Burke FD, Bradley MJ, Sinha S, Wilgis EF, Dubin NH.
The Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK.

AIM: To investigate the non-operative primary care management (splintage, task modification advice, steroid injections and oral medications) of carpal tunnel syndrome before patients were referred to a hand surgeon for decompression. DESIGN AND SETTING: Preoperative data were obtained on age, gender, body mass index, employment, symptom duration, and preoperative clinical stage for patients undergoing carpal tunnel decompression (263 in the USA, 227 in the UK). RESULTS: Primary care physicians made relatively poor use of beneficial treatment options with the exception of splintage in the US (73% of cases compared with 22.8% in the UK). Steroid injections were used in only 22.6% (US) and 9.8% (UK) of cases. Task modification advice was almost never given. Oral medication was employed in 18.8% of US cases and 8.9% of UK cases. CONCLUSIONS: This study analyses the non-operative modalities available and suggests that there is scope for more effective use of non-operative treatment before referral for carpal tunnel decompression.

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Muscle Nerve. 2007 Jul 6; [Epub ahead of print]
Postoperative splinting after open carpal tunnel release does not improve functional and neurological outcome.
Huemer GM, Koller M, Pachinger T, Dunst KM, Schwarz B, Hintringer T.
Department of Plastic Surgery, Sisters of Mercy Hospital, Seilerstaette 4, 4020 Linz, Austria.

Although surgical division of the transverse carpal ligament is the operative treatment of choice for carpal tunnel syndrome (CTS), controversy exists about the immediate postoperative treatment regimen. Splinting for up to 6 weeks after surgery is recommended by some investigators. We therefore evaluated effectiveness of splinting after open carpal tunnel surgery by a randomized, controlled trial. Fifty consecutive patients with clinically and electrophysiologically confirmed idiopathic CTS were assigned to open carpal tunnel release and randomized to receiving a light bandage (25 patients) or a bulky dressing with a volar splint (25 patients) for 2 days each. All patients were followed up at 3 months. Parameters retrieved were pain as measured using a visual analog scale, two-point discrimination, and grip strength, and nerve conduction studies. At follow-up, all patients reported definite improvement of symptoms, but there was no statistically significant difference between the two groups for any of our outcome measures. Thus, postoperative splinting after open carpal tunnel release does not yield any benefit to eventual outcome. In fact, it adds to the overall operating time and can safely be abandoned. Muscle Nerve, 2007.

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Clin Rehabil. 2007 Apr;21(4):299-314.
A systematic review of conservative treatment of carpal tunnel syndrome.
Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L.
Department of Physical Medicine and Rehabilitation, Catholic University, Rome, Italy.

OBJECTIVE: To assess the effectiveness of conservative therapy in carpal tunnel syndrome. DATA SOURCES: A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. REVIEW METHODS: RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). RESULTS: Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. CONCLUSION: There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective.

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Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001554. Update of:
Cochrane Database Syst Rev. 2002;(4):CD001554.
Local corticosteroid injection for carpal tunnel syndrome.
Marshall S, Tardif G, Ashworth N.
University of Ottawa, Physical Medicine & Rehabilitation, Rehabilitation Center, 505 Smyth Road, Ottawa, Ontario, Canada. smarshall@ottawahospital.on.ca

BACKGROUND: Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness is unknown. OBJECTIVES: To evaluate the effectiveness of local corticosteroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials register (searched May 2006), MEDLINE (searched January 1966 to May 2006), EMBASE (searched January 1980 to May 2006) and CINAHL (searched January 1982 to May 2006). SELECTION CRITERIA: Randomized or quasi-randomized studies. DATA COLLECTION AND ANALYSIS: Three authors independently selected the trials and rated their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated. MAIN RESULTS: We included 12 studies with altogether 671 participants. Two high quality randomized controlled trials with altogether 141 participants demonstrated clinical improvement of carpal tunnel syndrome at one month or less following local corticosteroid compared to placebo injection (relative risk 2.58 (95% confidence intervals 1.72 to 3.87)). One trial compared local corticosteroid injection to oral corticosteroid and at 12 weeks after treatment there was significantly more improvement in the injection group (mean difference -7.10 (95% confidence intervals -11.68 to -2.52)). In one trial, the rate of improvement after one month was greater after local than systemic corticosteroid injection (relative risk 3.17 (95% confidence intervals 1.02 to 9.87)). In one trial, symptoms did not improve significantly more in the injection group at eight weeks after injection compared to treatment with anti-inflammatory medication and splinting (mean difference 0.10 (95% confidence intervals -0.33 to 0.53)). Two injections versus one injection of local corticosteroid did not provide further clinical improvement, mean difference -3.80 (95% CI -9.27 to 1.67). AUTHORS' CONCLUSIONS: Local corticosteroid injection for carpal tunnel syndrome provides greater clinical improvement in symptoms one month after injection compared to placebo. Significant symptom relief beyond one month has not been demonstrated. Local corticosteroid injection provides significantly greater clinical improvement than oral corticosteroid for up to three months. Local corticosteroid injection does not significantly improve clinical outcome compared to either anti-inflammatory treatment and splinting after eight weeks or Helium-Neon laser treatment after six months. Two local corticosteroid injections do not provide significant added clinical benefit compared to one injection.

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J Clin Epidemiol. 2007 Feb;60(2):110-7. Epub 2006 Sep 7.
Exercise proves effective in a systematic review of work-related complaints of the arm, neck, or shoulder.
Verhagen AP, Karels C, Bierma-Zeinstra SM, Feleus A, Dahaghin S, Burdorf A, Koes BW.
Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands. a.verhagen@erasmusmc.nl

OBJECTIVE: Interventions such as physiotherapy and ergonomic adjustments play a major role in the treatment of most work-related complaints of the arm, neck, and/or shoulder (CANS). We evaluated whether conservative interventions have a significant impact on outcomes for work-related CANS. STUDY DESIGN AND SETTING: A systematic review was conducted. Only (randomized) trials studying interventions for patients suffering from work-related CANS were included. Interventions may include exercises, relaxation, physical applications, and workplace adjustments. Two authors independently selected the trials, assessed methodological quality, and extracted data. RESULTS: We included 26 studies (in total 2,376 patients); 23 studies included patients with chronic nonspecific complaints. Over 30 interventions were evaluated and 7 main subgroups of interventions could be determined, of which the subgroup "exercises" was the largest one. Overall, the quality of the studies appeared to be poor. CONCLUSION: There is limited evidence for the effectiveness of exercises when compared to massage, adding breaks during computer work, massage as add-on treatment to manual therapy, manual therapy as add-on treatment to exercises, and some keyboards in people with carpal tunnel syndrome when compared to other keyboards or placebo. For other interventions no clear effectiveness could be demonstrated.

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J Hand Ther. 2007 Jan-Mar;20(1):20-7; quiz 28.
New carpal ligament traction device for the treatment of carpal tunnel syndrome unresponsive to conservative therapy.
Porrata H, Porrata A, Sosner J.
Department of Physical Medicine and Rehabilitation, Saint Vincent Catholic Medical Centers of New York, Manhattan, New York, USA.

This study evaluated the treatment efficacy and patient satisfaction of a new hand traction device called C-TRAC in patients that failed conservative therapy for carpal tunnel syndrome (CTS). Patients were diagnosed with electromyography and nerve conduction studies. Only patients with a positive Phalens test and a Visual Analog Scale (VAS) of more than 5/10 were eligible for the study. The patients had tried nonsteroidal anti-inflammatory drugs (NSAIDS), resting hand splint during the night, acupuncture, and hand therapy for a minimum of four months. To test C-TRAC as the sole treatment for CTS, patients included in the study stopped all other forms of therapy (NSAIDS, hand therapy, acupuncture, massage, manipulations, and steroid injections). A group of 19 patients used C-TRAC hand traction device for 5 minutes three times daily for four weeks. After the four-week period the device was used as needed. The patients were followed up weekly for four weeks, then at seven months. VAS was used to assess pain, tingling, and numbness in the treated hand. The number of times patients woke up at night and satisfaction with the use of the device were also evaluated. The average VAS for pain decreased from 8.53 to 1.05. The average tingling decreased from 8.15 to 0.95. The average numbness decreased from 8.47 to 0.95. The average number of times patients woke up per night because of CTS symptoms decreased from 3.05 to 0.10. Patients showed significant improvement at four weeks and results were maintained at seven months follow-up. Fifteen patients (79%) rated their treatment as excellent and four (21%) as good and none (0%) as fair or poor. CLINICAL RELEVANCE: This device is very effective and well tolerated in treatment of CTS in patients that failed conservative therapy.

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Postgrad Med J. 2007 Jan;83(975):40-3.
Basal thumb arthritis.
Dias R, Chandrasenan J, Rajaratnam V, Burke FD.
Pulvertaft Hand Centre, Derby, UK.

Basal thumb arthritis is a common condition seen in hand clinics across the United Kingdom and is often associated with other pathological conditions such as carpal tunnel syndrome and scaphotrapezial arthritis. Typically, patients complain of pain localised to the base of the thumb. This pain is often activity related, particularly after excessive use involving forceful pinch. A detailed history and examination is normally all that is needed to make the diagnosis. Provocative manoeuvres may be helpful in localising symptoms to the basal joint with degenerative changes or synovitis. Radiographs are useful for confirming the diagnosis and staging the disease in order to plan for surgery. The mainstay of initial treatment of basal thumb arthritis of any stage is activity modifications, rest, nonsteroidal anti-inflammatory drugs, exercises and splinting. A variety of surgical procedures are available to treat the condition when conservative measures have failed, in order to control symptoms and improve function. We review the current literature and discuss the clinical aspects of this condition, staging, and treatment options available, and the difficulties treating this group of patients.

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J Manipulative Physiol Ther. 2007 Jan;30(1):50-61.
A pilot study comparing two manual therapy interventions for carpal tunnel syndrome.
Burke J, Buchberger DJ, Carey-Loghmani MT, Dougherty PE, Greco DS, Dishman JD.
New York Chiropractic College, Department of Research, Seneca Falls, NY, USA. jburke@nycc.edu

OBJECTIVE: The purpose of this study was to determine the clinical efficacy of manual therapy interventions for relieving the signs and symptoms of carpal tunnel syndrome (CTS) by comparing 2 forms of manual therapy techniques: Graston Instrument-assisted soft tissue mobilization (GISTM) and STM administered with the clinician hands. METHODS: The study was a prospective comparative research design in the setting of a research laboratory. Volunteers were recruited with symptoms suggestive of CTS based upon a phone interview and confirmed by electrodiagnostic study findings, symptom characteristics, and physical examination findings during an initial screening visit. Eligible patients with CTS were randomly allocated to receive either GISTM or STM. Interventions were, on average, twice a week for 4 weeks and once a week for 2 additional weeks. Outcome measures included (1) sensory and motor nerve conduction evaluations of the median nerve; (2) subjective pain evaluations of the hand using visual analog scales and Katz hand diagrams; (3) self-reported ratings of symptom severity and functional status; and (4) clinical assessments of sensory and motor functions of the hand via physical examination procedures. Parametric and nonparametric statistics compared treated CTS hand and control hand and between the treatment interventions, across time (baseline, immediate post, and at 3 months' follow-up). RESULTS: After both manual therapy interventions, there were improvements to nerve conduction latencies, wrist strength, and wrist motion. The improvements detected by our subjective evaluations of the signs and symptoms of CTS and patient satisfaction with the treatment outcomes provided additional evidence for the clinical efficacy of these 2 manual therapies for CTS. The improvements were maintained at 3 months for both treatment interventions. Data from the control hand did not change across measurement time points. CONCLUSIONS: Although the clinical improvements were not different between the 2 manual therapy techniques, which were compared prospectively, the data substantiated the clinical efficacy of conservative treatment options for mild to moderate CTS.

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J Hand Surg [Am]. 2006 Nov;31(9):1483-9.
Standard open decompression in carpal tunnel syndrome compared with a modified open technique preserving the superficial skin nerves: a prospective randomized study.
Siegmeth AW, Hopkinson-Woolley JA.
Department of Trauma and Orthopaedics, Ipswich Hospital, Ipswich, United Kingdom.

PURPOSE: A common surgical treatment for carpal tunnel syndrome is open carpal tunnel decompression. This involves skin incision followed by sharp dissection straight down through fat and palmar fascia to the transverse carpal ligament, which is then divided. The incidence of scar discomfort ranges from 19% to 61%, and its cause is not fully understood. We conducted a prospective randomized controlled trial to investigate whether preservation of superficial nerve branches crossing the incision site reduces the incidence and severity of postoperative scar pain after open carpal tunnel release. METHODS: Forty-two patients with bilateral idiopathic carpal tunnel syndrome (84 hands) were included in the study. The patients were randomized to determine which hand was to have carpal tunnel decompression using a technique that would try to preserve the superficial nerve branches. The other hand had open carpal tunnel decompression without any attempt to preserve the superficial nerve branches. An assessment of each hand in each patient was performed immediately before surgery and at 6 weeks, 3 months, and 6 months after surgery. This assessment was performed with a questionnaire based on the Patient Evaluation Measure. RESULTS: We found no evidence of a difference in scar pain between the 2 methods at 6 weeks, 3 months, and 6 months. There was a significant difference in the length of surgery between the 2 groups. CONCLUSIONS: Scar pain scores in this series of open carpal tunnel decompressions were similar, whether or not an attempt was made to identify and preserve superficial nerve branches crossing the wound.

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Handchir Mikrochir Plast Chir. 2006 Oct;38(5):300-5.
[Surgical treatment of persisting and recurrent carpal tunnel syndrome from 1999 to 2003]
[Article in German]
Pulzl P, Estermann D, Piza-Katzer H.
Universitatsklinik fur Plastische und Wiederherstellungschirurgie, Medizinische Universitat Innsbruck. petra.puelzl@uibk.ac.at

The operative treatment of carpal tunnel syndrome is relatively simple and is carried out by doctors from various surgical specialities. In cases of persisting pain or postoperative worsening of the condition, the indication for the procedure could have been wrong or an iatrogenic complication may have to be taken into consideration. We have analysed 42 patients (48 hands) who underwent surgical treatment for carpal tunnel release from 1999 to 2003. We treated eight men and 34 women with an average age of 56 years in this way. Ten patients were initially operated upon by endoscopic release. We found an incompletely transected or even untouched retinaculum flexorum in 16 patients. In eight patients we found an iatrogenic nerve lesion and 24 patients developed serious scarring. Revision surgery should be undertaken only by a surgeon who is a specialist in hand surgery and has extensive experience in this field. In the same context, postoperative hand therapy is essential for a good result, which is performed by occupational therapists in our clinic.

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MMW Fortschr Med. 2006 Sep 28;148(39):30-2.
[Clinical presentation, diagnosis and treatment of the carpal tunnel syndrome]
[Article in German]
Lukas B.
Zentrum fur Handchirurgie, Mikrochirurgie und Plastische Chirurgie, Orthozentrum Munchen. Blukas@schoen-kliniken.de

The carpal tunnel syndrome is the most common of the compression syndromes. The leading symptom is the "falling asleep" of the radial-sided fingers. The diagnosis is confirmed by the neurological examination. In the early stage, conservative treatment is justified, but in the advanced stage surgical decompression (carpal tunnel release) involving splitting of the transverse carpal ligament is indicated. In the hands of an experienced hand surgeon the operation is a routine procedure with a low complication rate.

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Plast Reconstr Surg. 2006 Sep 15;118(4):947-58; discussion 959-60.
Surgery versus conservative therapy in carpal tunnel syndrome in people aged 70 years and older.
Ettema AM, Amadio PC, Cha SS, Harrington JR, Harris AM, Offord KP.
Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, Minn., USA.

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.

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Minim Invasive Neurosurg. 2006 Aug;49(4):216-9.
Endoscopic carpal tunnel release in the elderly.
Nagaoka M, Nagao S, Matsuzaki H.
Orthopaedic Department, Surugadai Nihon University Hospital, Tokyo, Japan. mnagaoka@mub.biglobe.ne.jp

The present study is aimed to clarify the postoperative outcome of endoscopic carpal tunnel release in elderly patients with carpal tunnel syndrome. Endoscopic carpal tunnel release was performed on 37 hands of 27 patients (2 men, 25 women) who were aged 70 years or older and clinically and electrophysiologically diagnosed with carpal tunnel syndrome. Mean age at the time of surgery was 74.5 years (range: 70-85 years). Mean postoperative follow-up was 35.5 months (range: 12-114 months). Pain was present preoperatively in 20 hands, but quickly resolved postoperatively in all cases. Numbness completely disappeared in 13 of 37 hands (35.1%), but some degree of numbness remained in the remaining cases. Preoperative severity of thenar muscle atrophy was none in 4 hands, mild in 7 hands, moderate in 12 hands and severe in 14 hands. Postoperative severity of thenar muscle atrophy at final follow-up was none in 13 hands, mild in 16 hands, moderate in 2 hands and severe in 6 hands, confirming that thenar muscle atrophy improves even in elderly patients. However, moderate or severe thenar muscle atrophy remained in 8 hands (21.6%). Endoscopic carpal tunnel release should be considered in the elderly, even though clinical symptoms may not improve substantially in advanced cases.
 

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