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Carpal Tunnel Research: 2002-2006
Neurosurgery. 2006 Aug;59(2):333-40; discussion 333-40.
Dual-portal endoscopic release of the transverse ligament in
carpal tunnel syndrome: results of 411 procedures with special reference to
technique, efficacy, and complications.
Oertel J, Schroeder HW, Gaab MR.
Department of Neurosurgery, Hannover Nordstadt Hospital, Hannover Medical
School, Hannover, Germany. oertelj@freenet.de
OBJECTIVE: Endoscopic release of carpal tunnel syndrome is still under debate.
The main advantages of the technique are considered to be minor postoperative
pain and a more rapid postoperative recovery. Disadvantages are thought to be
the impossibility of a direct median nerve neurolysis and a higher surgical
complication rate, including injury to the median nerve. METHODS: The results of
411 consecutive endoscopic carpal tunnel procedures performed between March 1995
and September 2004 are presented. All patients were prospectively followed.
RESULTS: In the present series, a success rate of 98.05% was observed. There was
no permanent morbidity and, in particular, there was no injury of the median
nerve. In four (0.97%) patients, the preoperative symptoms did not improve. In
two (0.49%) of these patients, an incomplete release of the carpal ligament
occurred. In another four patients (0.97%), a switch to open surgery was
required. CONCLUSION: The present data prove that the endoscopic technique is a
safe and reliable technique for carpal tunnel surgery. The data do not support
the current discussion of a higher risk of median nerve injury with endoscopic
carpal tunnel surgery. Thus, for our group, the endoscopic technique represents
the therapy of choice for the primary idiopathic carpal tunnel syndrome.
-----
Rheumatol Int. 2006 Jul 27; [Epub ahead of print]
Comparison of splinting, splinting plus local steroid injection
and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome.
Ucan H, Yagci I, Yilmaz L, Yagmurlu F, Keskin D, Bodur H.
2nd Department of Physical Medicine and Rehabilitation, Ankara Numune Education
and Research Hospital, Ankara, Turkey.
The objective of this study was to compare the short- and long-term efficacies
of splinting (S), splinting plus local steroid injection (SLSI), and open carpal
tunnel release (OCTR) in mild or moderate idiopathic carpal tunnel syndrome
(CTS). Patients with mild or moderate idiopathic CTS who experienced symptoms
for over 6 months were included in the study. The patients were evaluated for
the baseline and the third and sixth month scores after treatment. Follow-up
criteria were ENMG parameters, Boston Questionnaire, and patient satisfaction.
Fifty-seven hands completed the study. Twenty-three hands had been splinted for
3 months. Twenty-three hands were given a single steroid injection and splinted
for 3 months, and 11 hands were operated. In the first 3 months, all treatment
methods provided significant improvements in both clinical and EMG parameters in
which OCTR had better outcomes on median sensorial nerve velocity at palm wrist
segment. In the second 3 months, while the clinical and EMG parameters began to
deteriorate in S and SLSI group, OCTR group continued to improve, and BQ
functional capacity score of OCTR group was statistically better than that in
conservative methods (P = 0.03). S and SLSI treatments improved clinical and EMG
parameters comparable to OCTR in short term. However, these beneficial effects
were transient in the sixth month follow-up and OCTR was superior to
conservative treatments.
-----
Int J Clin Pract. 2006 Jul;60(7):820-8.
Comparison of three conservative treatment protocols in carpal
tunnel syndrome.
Baysal O, Altay Z, Ozcan C, Ertem K, Yologlu S, Kayhan A.
Department of Physical Medicine and Rehabilitation, Inonu University, Malatya,
Turkey. ozlembe@inonu.edu.tr
The aim of this study was to investigate and compare the therapeutic effect of
three different combinations in the conservative treatment of carpal tunnel
syndrome (CTS) by means of clinical and electrophysiological studies. The
combinations included tendon- and nerve-gliding exercises in combination with
splinting, ultrasound treatment in combination with splinting and the
combination of ultrasound, splinting, tendon- and nerve-gliding exercises. A
total 28 female patients (56 wrists) with clinical and electrophysiologic
evidence of bilateral CTS were studied. In all patient groups, the treatment
combinations were significantly effective immediately and 8 weeks after the
treatment. The results of the long-term patient satisfaction questionnaire
revealed that symptomatic improvement is more prominent in the group treated
with splinting, exercise and ultrasound therapy combination. Our results suggest
that a combination of splinting, exercise and ultrasound therapy is a preferable
and an efficacious conservative type of treatment in CTS.
-----
BMJ. 2006 Jun 24;332(7556):1473. Epub 2006 Jun 15. Comment in:
BMJ. 2006 Jun 24;332(7556):1463-4.
Outcomes of endoscopic surgery compared with open surgery for
carpal tunnel syndrome among employed patients: randomised controlled trial.
Atroshi I, Larsson GU, Ornstein E, Hofer M, Johnsson R, Ranstam J.
Department of Orthopaedics, Hassleholm and Kristianstad Hospitals, SE-281 25
Hassleholm, Sweden. Isam.Atroshi@skane.se
Free full text: http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=16777857
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.
-----
Eura Medicophys. 2006 Jun;42(2):121-6.
Neutral wrist splinting in carpal tunnel syndrome: a 3- and
6-months clinical and neurophysiologic follow-up evaluation of night-only splint
therapy.
Premoselli S, Sioli P, Grossi A, Cerri C.
Unit of Neurorehabilitation, Trabattoni-Ronzoni Hospital, Seregno, Milan, Italy.
AIM: The aim of the study was to evaluate the long-term efficacy of night-only
splint wear therapy for carpal tunnel syndrome (CTS). METHODS: We conducted a
randomized case-control trial with evaluation after three and six months of
follow-up of outpatients with mild, recent onset symptoms of CTS recruited from
the department clinic. Fifty patients (50 hands) were enrolled, of which 36
completed the study at 6 months. The case group utilized a thermoplastic neutral
wrist splint for night-only wear. Outcome measures were instrumental parameters
(sensory and motor nerve conduction velocity), symptom and function alterations
(as measured by Levine's self-administered questionnaire), clinical parameters
(pressure-provocative and Phalen tests). RESULTS: Improvements were observed in
Levine's symptom status score at the three-month (P=0.001) and the six-month
(P=0.001) follow-up visits, in functional score (P=0.0001) and (P=0.0004), in
median distal sensory latency (P=0.01) and (P=0.02), in pressure-provocative
test outcome (P=0.01) and (P=0.003), in Phalen test outcome (P=0.04) and
(P=0.05) respectively. CONCLUSION: Symptom relief and neurophysiological
improvement after night-only splint wear therapy lasted up to the six-month
follow-up visit.
-----
Int Orthop. 2006 May 17; [Epub ahead of print]
Patient satisfaction following carpal-tunnel decompression: a
comparison of patients with and without osteoarthritis of the wrist.
Joshy S, Thomas B, Ghosh S, Haidar SG, Deshmukh SC.
Trauma and Orthopaedics, City Hospital, B18 7QH, Birmingham, UK.
The aim of this study was to assess whether surgical decompression for
carpal-tunnel syndrome (CTS) in the presence of primary or secondary
osteoarthritis of the wrist is associated with poorer patient satisfaction. We
did a retrospective matched cohort study. Twenty-four patients who underwent
surgical decompression for CTS secondary to osteoarthritis were identified by
reviewing the notes and the radiographs. A control group consisted of 24
patients without osteoarthritis of the wrist who underwent carpal-tunnel
decompression. The control group was matched for age, sex, side, and neuro-physiological
severity of the nerve compression. In the group with osteoarthritis of the
wrist, 17 (71%) patients reported their symptom relief as satisfactory, and 7
(29%) reported the results as unsatisfactory. In the control group, 23 (96%)
patients reported their symptom relief as satisfactory, and 1 (4%) reported the
results as unsatisfactory (P=0.0325). In conclusion, patient satisfaction
following surgical decompression in patients with secondary CTS due to
osteoarthritis was significantly lower compared to patients without
osteoarthritis of the wrist.
-----
Photomed Laser Surg. 2006 Apr;24(2):101-10.
Photobiomodulation of pain in carpal tunnel syndrome: review of
seven laser therapy studies.
Naeser MA.
Department of Neurology, Boston University School of Medicine, MA 02130, USA.
mnaeser@bu.edu
In this review, seven studies using photoradiation to treat carpal tunnel
syndrome (CTS) are discussed: two controlled studies that observed real laser to
have a better effect than sham laser, to treat CTS; three openprotocol studies
that observed real laser to have a beneficial effect to treat CTS; and two
studies that did not observe real laser to have a better effect than a control
condition, to treat CTS. In the five studies that observed beneficial effect
from real laser, higher laser dosages (9 Joules, 12-30 Joules, 32 J/cm(2), 225
J/cm(2)) were used at the primary treatment sites (median nerve at the wrist, or
cervical neck area), than dosages in the two studies where real laser was not
observed to have a better effect than a control condition (1.8 Joules or 6
J/cm(2)). The average success rate across the first five studies was 84% (SD,
8.9; total hands = 171). The average pain duration prior to successful
photoradiation was 2 years. Photoradiation is a promising new, conservative
treatment for mild/moderate CTS cases (motor latency < 7 msec; needle EMG,
normal). It is cost-effective compared to current treatments.
-----
Eura Medicophys. 2006 Mar 24; [Epub ahead of print]
Neutral wrist splinting in carpal tunnel syndrome: a 3- and
6-months clinical and neurophysiologic follow-up evaluation of night-only splint
therapy.
Premoselli S, Sioli P, Grossi A, Cerri C.
Unit of Neurorehabilitation, Trabattoni-Ronzoni Hospital, Seregno, Milan, Italy.
AIM: The aim of the study was to evaluate the long-term efficacy of night-only
splint wear therapy for carpal tunnel syndrome (CTS). METHODS: We conducted a
randomized case-control trial with evaluation after three and six months of
follow-up of outpatients with mild, recent onset symptoms of CTS recruited from
the department clinic. Fifty patients (50 hands) were enrolled, of which 36
completed the study at 6 months. The case group utilized a thermoplastic neutral
wrist splint for night-only wear. Outcome measures were instrumental parameters
(sensory and motor nerve conduction velocity), symptom and function alterations
(as measured by Levine's self-administered questionnaire), clinical parameters
(pressure-provocative and Phalen tests). RESULTS: Improvements were observed in
Levine's symptom status score at the three-month (P=0.001) and the six-month
(P=0.001) follow-up visits, in functional score (P=0.0001) and (P=0.0004), in
median distal sensory latency (P=0.01) and (P=0.02), in pressure-provocative
test outcome (P=0.01) and (P=0.003), in Phalen test outcome (P=0.04) and
(P=0.05) respectively. CONCLUSION: Symptom relief and neurophysiological
improvement after night-only splint wear therapy lasted up to the six-month
follow-up visit.
-----
J Fam Pract. 2006 Mar;55(3):209-14.
Lidocaine patch 5 for carpal tunnel syndrome: how it compares
with injections: a pilot study.
Nalamachu S, Crockett RS, Mathur D.
Mid-America Physiatrists, PA, Overland Park, KS 66211, USA. nalamachu@sbcglobal.net
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.
-----
Pain Med. 2006 Jan-Feb;7(1):16-24.
Clinically significant placebo analgesic response in a pilot
trial of botulinum B in patients with hand pain and carpal tunnel syndrome.
Breuer B, Sperber K, Wallenstein S, Kiprovski K, Calapa A, Snow B, Pappagallo M.
Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New
York, New York, USA.
Objective. We conducted a pilot trial to assess the effect of botulinum toxin B
on palmar pain and discomfort in carpal tunnel syndrome (CTS) patients. Design.
Randomized, double-blind, placebo-controlled. Patients. Twenty ambulatory CTS
patients. Intervention. Botulinum toxin B or placebo injections into three
hypothenar muscles anatomically linked or attached to the carpal tunnel and its
tentorium, that is, the Opponens Digiti Minimi and Flexor Digiti Minimi, located
with electromyography (EMG), and the Palmaris Brevis Muscle, anatomically
located without EMG. Setting. New York City hospital. Outcome Measures. Outcomes
were measured with numeric ratings, with higher scores indicating worse
outcomes. Daily, subjects recorded their 0-10 numeric ratings of overall pain
levels and pain-related sleep disturbances. During weekly telephone calls, they
reported their 0-10 ratings for overall pain, pain-related sleep disturbance,
and CTS-related tingling during the night and day as experienced over the
preceding 24 hours. For each of four clinic visits, we averaged each subject's
ratings of nine quality of life indicators from the West Haven-Yale
Multidimensional Pain Inventory (WHYMPI), each measured on a 0-6 numeric scale.
Results. Over the 13-week trial, compared to baseline scores, the following
outcomes predominantly showed decreases of statistical significance (P </=
0.050) or borderline significance (0.050 < P </= 0.10) for weeks 2 through 8:
overall pain per daily diary entries and per weekly telephone reports, and
pain-related sleep disturbance in the placebo group per phone report and in the
botulinum toxin B group per diary report. CTS painful night tingling and day
tingling, as well as the average scores of the WHYMPI quality of life
indicators, showed improvements with statistical or borderline significance for
almost each follow-up week. Between-group analyses, however, demonstrated that
at each follow-up week, there was no statistically significant difference
between the two study groups regarding changes from baseline in any study
outcome. Conclusion. Botulinum toxin B is not dramatically superior to placebo
for the relief of CTS symptoms. Possible explanations of the improvements in
each study group are explored.
-----
Scand J Plast Reconstr Surg Hand Surg. 2006;40(1):41-5.
Carpal tunnel syndrome during pregnancy.
Finsen V, Zeitlmann H.
Department of Neuroscience, Faculty of Medicine, NTNU, Trondheim, Norway.
Vilh.Finsen@medisin.ntnu.no
Carpal tunnel syndrome is common during pregnancy. The symptoms usually
disappear after delivery, but how soon has not been established. Thirty pregnant
women with the syndrome reported to us the degree of pain in their hands every
week before, and daily after, delivery. Pain was graded on a scale from 0 (none)
to 10 (worst imaginable). The prevalence of the syndrome during pregnancy was
about 2%. The mean pain score was 5.6 (SD 2.0) at referral and this was reduced
by 1.2 (SD 2.2) after wearing an orthosis for a week. After this, it stayed
almost unchanged until delivery. The score fell by half during the first week
after parturition and by half again during the next week. The reduction in score
was strongly correlated with loss of the weight gained during pregnancy (r =
0.97; p <0.001). Although symptoms may persist for some weeks after delivery,
the severity declines quickly.
-----
Plast Reconstr Surg. 2006 Jan;117(1):177-85.
Endoscopic carpal tunnel release: a review of 753 cases in 486
patients.
Schmelzer RE, Della Rocca GJ, Caplin DA.
BACKGROUND: Endoscopic carpal tunnel release is gaining increasing acceptance
relative to the standard open carpal tunnel release for the treatment of carpal
tunnel syndrome. Concerns about endoscopic carpal tunnel release include
effectiveness of therapy and complication rates. This study attempted to
evaluate outcomes of endoscopic carpal tunnel release in a large patient cohort.
METHODS: Four hundred eighty-six patients (753 hands) with carpal tunnel
syndrome who underwent endoscopic carpal tunnel release by a single surgeon were
reviewed retrospectively. Data included demographics, subjective complaints,
prior interventions, preoperative examination findings, and postoperative
follow-up. All follow-up data were obtained from a single, independent,
occupational therapy clinic. RESULTS: Median patient age was 48 years. Three
hundred seventy-seven patients were gainfully employed at presentation, and 206
filed a worker's compensation claim. Median symptom duration was 2 years.
Nonoperative therapy was ineffective in 151 patients. Preoperative nerve
conduction studies were consistent with carpal tunnel syndrome in 472 patients
(97 percent); all patients had either physical examination findings or nerve
conduction studies consistent with carpal tunnel syndrome. Four hundred
eighty-six patients (100 percent) obtained symptom relief. Complications
included one transient median nerve neurapraxia, six complaints of residual
pain, and one complaint of hypersensitivity. Worker's compensation patients and
non-worker's compensation patients returned to work full-duty at similar times
postoperatively. Ninety percent of employed patients returned to their original
occupation. CONCLUSIONS: The authors' data indicate that an endoscopic approach
for the treatment of carpal tunnel syndrome is safe and effective. Patients
demonstrated a high return-to-work rate and an extremely low complication rate.
The data challenge the belief that endoscopic carpal tunnel release results in
higher complication rates.
-----
J Neurol. 2005 Dec 15; [Epub ahead of print]
Injection with methylprednisolone in patients with the carpal
tunnel syndrome A randomised double blind trial testing three different doses.
Dammers JW, Roos Y, Veering MM, Vermeulen M.
Department of Neurology, Medical Centre Alkmaar, 501, 1800 AM, Alkmaar, The
Netherlands.
OBJECTIVE: To determine the efficacy of 20, 40 and 60mg methylprednisolone
injections in patients with the carpal tunnel syndrome.METHODS: Included were
patients with signs and symptoms of carpal tunnel syndrome of more than 3 months
duration confirmed by electrophysiological tests. Patients were in a double
blind trial randomised to treatment consisting of injections proximal to the
carpal tunnel with 20, 40 or 60mg methylprednisolone. Primary outcome was
improvement of symptoms requiring no further treatment. These patients were
followed for one year.RESULTS: There were no significant differences in the
treatment response between the three randomised groups at one-year follow-up
(log rank analysis 1.51, 2df, 0.4711). In the 20, 40 and 60mg treatment groups,
56%, 53% and 73% of the patients respectively were free of important symptoms at
six months follow-up. Of the patients treated with one or two injections 22%
were finally referred to surgery within one year of the first treatment. No side
effects were recorded.CONCLUSION: A single local injection of methylprednisolone
20, 40 or 60 mg results in long lasting improvement in approximately half of the
patients. There is a trend in favour of the highest dose. A second injection may
further reduce the number of patients requiring surgery.
-----
Int J Clin Pract. 2005 Dec;59(12):1417-21.
Single vs. two steroid injections for carpal tunnel syndrome: a
randomised clinical trial.
Wong SM, Hui AC, Lo SK, Chiu JH, Poon WF, Wong L.
Department of Medicine, Prince of Wales Hospital, The Chinese University of Hong
Kong, Shatin, NT, Hong Kong.
We investigated the efficacy of a single vs. double steroid injections in the
treatment of carpal tunnel syndrome (CTS) in a randomised double-blind
controlled trial. Patients with idiopathic CTS were randomised into (i) one
group receiving a baseline methylprednisolone acetate injection plus a saline
injection 8 weeks later and (ii) a second group receiving methylprednisolone
acetate injection at baseline and at 8 weeks. The primary outcome was the Global
Symptom Score (GSS). Forty patients were recruited. By 40 weeks, the mean GSS
improved from 25.6 to 14.1 in the single-injection group whereas from 26.7 to
12.6 in the reinjection group, but there was no significant difference in GSS
between the two groups (p = 0.26). There were also no significant differences in
terms of electrophysiological and functional outcomes. The results suggest that
an additional steroid injection confers no added benefit to a single injection
in terms of symptom relief.
-----
Clin Invest Med. 2005 Oct;28(5):254-60.
Outcomes in carpal tunnel syndrome: symptom severity,
conservative management and progression to surgery.
Boyd KU, Gan BS, Ross DC, Richards RS, Roth JH, MacDermid JC.
Dept. of Surgery, University of Western Ontario, London, Ontario, Canada.
PURPOSE: This study investigated the relationship between severity of symptoms
and success of nonoperative and operative treatment in patients with carpal
tunnel syndrome (CTS). METHODS: An observational cohort study regarding the
management of CTS was conducted. Thirty patients referred to a tertiary hand
centre with a diagnosis of CTS were prospectively followed. Twenty-five of the
patients (47 affected hands) were available for long-term follow up to determine
management outcomes. Self-report symptoms and physical impairments were assessed
and documented at baseline, 6 weeks, and 12 weeks using the CTS Severity Score (SSS),
the Disability-Shoulder, Arm and Hand Score (DASH), and the Levine Functional
Score. Longer-term follow-up was conducted to identify status on outcome
measures and whether patients proceeded to surgery. RESULTS: Those who proceeded
to surgery (n = 27/47 hands) had higher initial CTS SSS and DASH scores and also
maintained higher scores compared to those who improved with conservative
management (p < 0.05). Improvements occurred in the SSS (P < 0.0001), Functional
Score (P < 0.001), and DASH score (P < 0.05) following surgery in the patients
resistant to conservative management. Recovery of grip and dexterity was less
satisfactory. DISCUSSION: This study suggests that the SSS is useful in the
triage of patients on surgical wait-lists as patients with high initial scores
or failure to change in short-term follow-up are likely to proceed to surgical
release. Despite prolonged symptoms and previous treatment, patients with lower
SSS scores had moderate success with a second trial of conservative management.
-----
Clin Rheumatol. 2005 Oct 25;:1-3 [Epub ahead of print]
A novel approach of local corticosteroid injection for the
treatment of carpal tunnel syndrome.
Habib GS, Badarny S, Rawashdeh H.
Rheumatology Clinic, Nazareth Hospital, Nazareth, Israel.
The objective of the study was to compare the favorable response rate, time
duration, and pain level of local corticosteroid injection using a novel
approach for the treatment of carpal tunnel syndrome vs a classic approach.
Patients with symptomatic carpal tunnel syndrome of less than 1-year duration
were randomized for local corticosteroid injection using either the classic
approach or a novel approach. In our approach (novel), we used a 29 gauge x
1/2-in. needle and a 1-ml insulin syringe containing 12 mg of methylprednisolone
mixed with 0.15 ml of lidocaine 2%, and the site of the injection was 2-3 cm
distal to the middle of wrist crease. In the classic approach, we used a 25
gauge x 3-cm needle and a 2-ml syringe injecting 35 mg of methylprednisolone
mixed with 0.5 ml of lidocaine 2%, 3-4 cm proximal to the wrist crease and just
ulnar to the tendon of the flexor carpi radialis muscle. Response rate was
evaluated 1, 3, 6, and 12 weeks after the injection, and also the duration of
time of the procedure and the level of pain using the visual analogue scale were
compared between the two groups. Forty-two patients signed the consent form, and
all of them completed the study [21 patients in the classic approach group
(group 1) and 21 patients in the novel approach group (group 2)]. The favorable
response rates were 100, 81, 71, and 57% in group 1 and 100, 71, 67, and 57% in
group 2 after 1, 3, 6, and 12 weeks, respectively. There was no significant
difference in the favorable response rate between the two groups (p=0.468, 95%
CI=-12-31%, after 3 weeks). The average duration of time of the procedure in
group 1 was 26.71+/-32.83 s compared to 8.48+/-1.123 s (p=0.021) in group 2. The
average grade of pain expressed by the patients in group 1 was 4.38+/-1.523
compared to 3.62+/-1.071 in group 2 (p=0.065). In conclusion, local
corticosteroid injection using the novel approach for the treatment of carpal
tunnel syndrome is helpful, and the favorable response rates are comparable to
those using the classic approach after 1, 3, 6, and 12 weeks. The novel approach
is much less time consuming and is not more painful.
-----
Curr Opin Neurol. 2005 Oct;18(5):581-5.
Carpal tunnel syndrome.
Bland JD.
East Kent Hospitals NHS Trust, Canterbury, Kings College Hospital NHS Trust,
London, UK.
PURPOSE OF REVIEW: Carpal tunnel syndrome, though generally successfully treated
by surgical decompression, still results in significant morbidity. The causes
remain unclear and there is uncertainty about appropriate investigations for
diagnosis and assessment of severity. The best nonsurgical treatment is yet to
be fully elucidated. Recent work has begun to cast some light on these
uncertainties. RECENT FINDINGS: The pathology of idiopathic carpal tunnel
syndrome is a noninflammatory fibrosis of the subsynovial connective tissue
surrounding the flexor tendons. Biochemical studies of surgical specimens
suggest that a variety of regulatory molecules may be inducing fibrous and
vascular proliferation and that this may be a response to mechanical stresses.
Ultrasound imaging has begun to demonstrate its ability to accurately image the
carpal canal contents and the diagnostic value of measurements of median nerve
cross-sectional area showing expansion of the nerve is becoming established. The
sensitivity and specificity of such measurements may be comparable to those of
nerve conduction studies, though their prognostic value remains unknown.
Nonsurgical treatment with steroid injection may be a more effective treatment
than previously recognized, and is under used. SUMMARY: Suspected carpal tunnel
syndrome should be investigated first with nerve conduction studies but
consideration should be given to the use of magnetic resonance imaging or
ultrasound imaging when diagnostic uncertainty remains, or there is a suspicion
of a space occupying lesion in the carpal canal, especially if endoscopic
surgery is contemplated. Treatment by local steroid injection should be
considered a valid alternative treatment, at least for milder cases.
-----
J Hand Ther. 2005 Jul-Sep;18(3):386-7.
Clinical outcomes of carpal tunnel release in patients 65 and
older.
Schwartz DA.
PURPOSE: The authors of this article present a study which examines the benefits
of Carpal Tunnel Release surgery in patients 65 years of age or older. A common
misconception among referring physicians holds that elderly patients have a
poorer recovery after peripheral nerve injury and repair than younger patients,
and that nerve conduction velocities naturally decrease with age. Therefore,
their attitude and reluctance to send patients to hand surgeons suggest the
belief that CTR surgery is less effective in the older population. Carpal Tunnel
Syndrome (CTS) is a compression neuropathy of the median nerve at the wrist.
Some studies suggest that CTS may be more prevalent and more severe in the
elderly. The authors conducted a prospective study of patients 65 years of age
or older who were seeking surgical release for treatment of CTS. These patients
were evaluated before and after surgery to determine the benefits of the
procedure for the older population. Method: Seventy-five patients and a total of
105 hands were enrolled in the study. The average age of participants was 75
years of age. Patients were evaluated prior to surgery and again at six months
after surgery. Thirty-one men and 35 women completed the 6-month follow up
evaluation. Ninety-four percent of the patients were right handed. Fifty-nine
percent of the patients had bilateral symptoms. The median duration of symptoms
was 24 months (range 2-180 months). The evaluation consisted of a detailed
history of hand dominance and symptoms including paresthesias, nocturnal
symptoms, and subjective weakness. The physical examination included Tinel's
sign, Phalen's sign, median nerve compression test, 2-pt discrimination, grip
and pinch strength measurements and thenar wasting. CHTs performed quantitative
sensory testing using a pressure-sensing device (Pressure Specified Sensory
Device, Sensory Measurement Services, LLC, Baltimore, MD). This allowed for
standardized grip and pinch strength measurements and static 2-pt discrimination
testing. The Michigan Hand Outcomes Questionnaire (MHQ) was used to assess
clinical outcomes. The MHQ evaluates overall hand function, activities of daily
living (ADL's), work performance, pain, aesthetics and satisfaction with hand
function. It is an internally consistent and validated measurement for patients
following hand surgery. Prior to surgery, patients were asked to rate
paresthesias, numbness, day pain, night pain and nocturnal weakness on a scale
of 1-5 (none, mild, moderate, severe, very severe). Results: After surgery,
patient symptoms of paresthesias, numbness, day pain, night pain and nocturnal
weakness were significantly decreased in severity with a p value of less than
.0001. Sixty-three percent of patients had complete relief of all symptoms.
Tinel's sign and Phalen's sign were significantly decreased after surgery. Grip
strength increased slightly while pinch strength increased significantly from
pre and post surgical measures (p < .02). Even thenar wasting, noted in 44% of
the patients prior to surgery, decreased to 29% after surgery (p < .01). The 6
scales of the MHQ (overall hand function, activities of daily living, work
performance, aesthetics, satisfaction with hand function and pain) all showed
significant improvement after surgery with a p value of less than .0001.
Discussion: In recognition of the fact that CTS is common among the elderly, and
that their symptoms are often more severe than in the general public, CTR should
be considered a viable course of treatment for this population. This study
demonstrates the benefits of surgical interventions in terms of improved
physical findings and most importantly, improved clinical outcomes. Despite long
duration of symptoms in this elderly population, pre-operative symptoms
decreased significantly. Overall, 83% of the patients were either completely
satisfied or very satisfied with their surgical outcome.
-----
Hand Surg. 2005 Jul;10(1):61-6.
Ideas and innovations: radial approach to carpal tunnel release
in conjunction with thumb carpometacarpal arthroplasty.
Tsai TM, Laurentin-Perez LA, Wong MS, Tamai M.
University of Louisville, Louisville, Kentucky, USA. research@cmki.org.
Several authors have written about the co-existence of thumb carpometacarpal
arthritis and carpal tunnel syndrome, and 4% to 43% of patients undergoing thumb
carpometacarpal arthroplasty also have a carpal tunnel release. Some authors
advocate that carpal tunnel release and thumb carpometacarpal arthroplasty
should be performed at the same time. We perform a combined thumb
carpometacarpal arthroplasty and radial approach carpal tunnel release through a
single incision. The purposes of this study are to (1) determine the safety of
this approach and (2) evaluate the effectiveness of this approach in decreasing
the pain and numbness observed prior to surgery. Eight patients had combined
thumb carpometacarpal arthroplasty and radial approach carpal tunnel release.
With an average follow up of 14 weeks, all patients reported an improvement in
pain and numbness. No nerve injuries occurred, and no difficulty in wrist
flexion was observed. One patient had pillar pain persisting at 19 weeks
follow-up. One patient had basilar thumb pain at 19 weeks, though this was
improved over pre-operative levels.
-----
Electromyogr Clin Neurophysiol. 2005 Jun;45(4):223-7.
The effect of carpal tunnel release on median nerve flattening
and nerve conduction.
El-Karabaty H, Hetzel A, Galla TJ, Horch RE, Lucking CH, Glocker FX.
Department of Neurology and Clinical Neurophysiology, University of Freiburg,
Germany.
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and
extensive surveys have been given on the time course of electrophysiological
findings pre- and postoperatively. In patients with clinical and
electrophysiological confirmed diagnosis of CTS surgical decompression of the
carpal tunnel is a first line treatment and has proven to be successfull in 70
to 90% of all cases. The objective of this work was to study the morphological
changes of the median nerve after endoscopic release of the carpal tunnel. We
used high resolution ultrasound to quantify flattening of the median nerve and
to calculate a flattening ratio before endoscopic release as well as 2 weeks and
3 months postoperatively. Ten patients with clinical and electrophysiological
confirmed CTS were included in the study. There was significant normalization of
the calculated flattening ratio of the median nerve already 2 weeks after
surgical release, whereas nerve conduction studies needed a longer period of
time to normalize and thus were still abnormal 3 months postoperatively. We
conclude that ultrasound is a simple and excellent objective method for
visualizing the morphological recovery of the median nerve very early after
decompression surgery. In complex cases with unsatisfactory outcome
ultrasonography may prove useful in confirming successfull or failed
decompression of the median nerve.
-----
Neurology. 2005 Jun 28;64(12):2074-8.
A randomized controlled trial of surgery vs steroid injection for
carpal tunnel syndrome.
Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, Li-Tsang CW, Wong LK, Boet R.
Division of Neurology, Department of Medicine, Prince of Wales Hospital, The
Chinese University of Hong Kong, Hong Kong, China. cfhui@cuhk.edu.hk
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.
-----
J Hand Surg [Am]. 2005 May;30(3):500-5.
The outcome of carpal tunnel decompression in elderly patients.
Townshend DN, Taylor PK, Gwynne-Jones DP.
Department of Orthopaedic Surgery, Dunedin Hospital, Great King Street, Dunedin,
New Zealand.
PURPOSE: To determine the outcomes of carpal tunnel decompression in elderly
patients and whether outcomes can be predicted by the severity of presurgical
nerve conduction study results. METHODS: We performed a retrospective study of
all patients over 70 years of age who had elective carpal tunnel release at
Dunedin Hospital between April 1999 and April 2002 with a minimum of 1-year
follow-up evaluation. A grading system for presurgical nerve conduction studies
was formulated that scored patients from 1 to 6 according to severity. Patients
were evaluated by a mailed questionnaire (Symptom Severity Score) with follow-up
telephone calls to nonresponders. RESULTS: Eighty-three carpal tunnel release
procedures performed in 70 patients were included in the study. Eighty percent
had marked to severe neurophysiologic changes (grades 4-6). The median
postsurgical Symptom Severity Score was 1.3 (inter-quartile range, 1.1-1.7).
Patients expressed satisfaction with the outcome of the surgery in 78 of 83
cases (94%). There was a significant relationship between presurgical nerve
conduction grade and postsurgical Symptom Severity Score. CONCLUSIONS: This
study shows that elderly patients have low postsurgical symptom scores and
express high levels of satisfaction after surgery for carpal tunnel syndrome.
There was a significant relationship between severity of neurophysiologic
abnormalities and a higher Symptom Severity Score after surgery. Severe
abnormality, however, should not exclude elderly patients from surgery.
-----
Rheumatology (Oxford). 2005 May;44(5):647-50. Epub 2005 Mar 1.
A prospective study of the long-term efficacy of local methyl
prednisolone acetate injection in the management of mild carpal tunnel syndrome.
Agarwal V, Singh R, Sachdev A, Wiclaff, Shekhar S, Goel D.
Department of Medicine, Government Medical College, Chandigarh, India. vikasagr@sgpgi.ac.in
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.
-----
Photomed Laser Surg. 2005 Apr;23(2):225-8.
Treatment of carpal tunnel syndrome with polarized polychromatic
noncoherent light (Bioptron light): a preliminary, prospective, open clinical
trial.
Stasinopoulos D, Stasinopoulos I, Johnson MI.
School of Health and Human Sciences, Leeds Metropolitan University, Leeds,
United Kingdom. d.stasinopoulos@yahoo.gr
OBJECTIVE: Our aim was to assess the efficacy of polarized polychromatic
noncoherent light (Bioptron light) in the treatment of idiopathic carpal tunnel
syndrome. BACKGROUND: Carpal tunnel syndrome is the most common compression
neuropathy, but no satisfactory conservative treatment is available at present.
METHOD: An uncontrolled experimental study was conducted in patients who visited
our clinic from mid-2001 to mid-2002. A total of 25 patients (22 women and three
men) with unilateral idiopathic carpal tunnel syndrome, mild to moderate
nocturnal pain, and paraesthesia lasting >3 months participated in the study.
The average age of the patients was 47.4 years and the average duration of
patients' symptoms was 5.2 months. Polarized polychromatic noncoherent light (Bioptron
light) was administered perpendicular to the carpal tunnel area. The irradiation
time for each session was 6 min at an operating distance of 5-10 cm from the
carpal tunnel area, three times weekly for 4 weeks. Outcome measures used were
the participants' global assessments of nocturnal pain and paraesthesia,
respectively, at 4 weeks and 6 months. RESULTS: At 4 weeks, two patients (8%)
had no change in nocturnal pain, six (24%) were in slightly less nocturnal pain,
12 (48%) were much better in regard to nocturnal pain and five (20%) were
pain-free. At 6 months, three patients (12%) were slightly better in regard to
nocturnal pain, 13 (52%) were much better regarding nocturnal pain, and nine
patients (36%) were pain-free. At 4 weeks, four patients (16%) had no change in
paraesthesia, five (20%) were slightly better, 13 patients (52%) were much
better, and three patients (12%) were without paraesthesia. At 6 months, two
patients (8%) had no change in paraesthesia, two (8%) were slightly better, 14
(56%) were much better, and seven (28%) were without paraesthesia. CONCLUSIONS:
Nocturnal pain and paraesthesia associated with idiopathic carpal tunnel
syndrome improved during polarized polychromatic noncoherent light (Bioptron
light) treatment. Controlled clinical trials are needed to establish the
absolute and relative effectiveness of this intervention.
-----
Acta Neurochir Suppl. 2005;92:41-5.
Endoscopic carpal tunnel release surgery: retrospective study of
390 consecutive cases.
Quaglietta P, Corriero G.
Neurosurgical Unit General Hospital of Cosenza, Cosenza, Italy. paolo.quaglietta@tin.it
Endoscopic carpal tunnel release (ECTR) surgery was developed by Okutsu and Chow
in 1989. Many reports indicated that the endoscopic technique reduces
postoperative morbidity with minimal incision, minimal pain and scarring, a
shortened recovery period and high level of patient satisfaction. To evaluate
these reports, a retrospective study was conducted with 390 procedures of
two-portal Chow technique for idiopathic carpal tunnel syndrome. Follow-up was
performed at 1, 3 and 6 months and overall results were backed up by telephone
questionnaire (Health Outcomes Carpal Tunnel Questionnaire, Health Outcomes,
Bloomington, MN, USA). Results were favourable in 98% and 2% unfavorable for
persistent pain. Rate of satisfaction of the patients was 90%. Average time of
patient's return to work was 20 days. Eleven procedures (2.8%) were converted to
open release. There was one case (0.2%) of incompleted section of the
perineurium due to failure of endoscopic visualization of the ligament. In this
case the procedure was converted to open and was completed with perineurium
sutura. In six cases (1.5%) there were injury to superficial palmar arch. During
the follow-up period there were no recurrences and no re-exploration. The mean
preoperatively obtainable distal motor latency (DML) and sensory conduction
velocity (SCV) values were 6.7 m/s and 29.2 m/s, respectively. The mean DML and
SVC values at final follow-up were 3.8 msec and 42.3 m/s, respectively. In
conclusion, ECTR can be used in the carpal tunnel syndrome and is a reliable
alternative to the open procedure with excellent self-report of patient
satisfaction. Reduced recovery period with minimal tissue violation and
incisional pain can be expected.
-----
Rheumatology (Oxford). 2005 Mar 1; [Epub ahead of print]
A prospective study of the long-term efficacy of local methyl
prednisolone acetate injection in the management of mild
carpal tunnel syndrome.
Agarwal V, Singh R, Sachdev A, Wiclaff, Shekhar S, Goel D.
Department of Medicine, Government Medical College Chandigarh, India.
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.
-----
Ther Umsch. 2005 Feb;62(2):139-44.
[Arthroscopic surgery]
[Article in German]
Bereiter H, Strobel M, Sommer Ch.
Spitaler Chur AG, Departement Chirurgie, Abteilung Orthopadie, Kantonsspital,
Chur. heinz.bereiter@scag.gr.ch
Although arthroscopy of the knee joint had already been reported during the
1930's, the general dissemination of this method first began in the 1970's. The
main reason for the rapid dissemination of this method was especially the fact
that in addition to diagnostics, therapeutic possibilities were recognized and
immediately implemented. This meant that arthroscopy had great potential and was
made well known since the surgery was minimally invasive. Today we can assume
that the technological side of the arthroscopic method is very widely developed
and new innovations only arise slowly. Innovations are mostly connected with new
innovative operating techniques. Surgery of the knee joint was the dominant
application of arthroscopy in the beginning. The method was quickly applied to
other joints. Today there is practically no joint which is inaccessible to
arthroscopy. From surgical and therapeutic perspectives, arthroscopy is most
frequently used today for the knee joint, followed by the shoulder joint, ankle
joint, elbow joint, hip joint as well as wrist joint. Arthroscopic surgery
within the field of joint surgery is regarded as indispensable. This specific
surgery needs corresponding ability and skill, which must be individually
acquired. Arthroscopic surgery evidently depends on technology and accordingly
requires a corresponding fully operational medical infrastructure and knowledge.
The big advantage of arthroscopic surgery lies in the minimally invasive
technique, which has reduced the primary postoperative mortality significantly.
Therefore, with good indicators the patient has decisive advantages as well as
good cost to benefit ratios.
-----
Arthritis Rheum. 2005 Feb;52(2):612-9.
Surgical decompression versus local steroid injection in carpal
tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical
trial.
Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I.
Primary Care Unit Gandhi, Madrid, Spain.
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.
-----
J Hand Surg [Am]. 2005 Jan;30(1):75-80.
Clinical outcomes of carpal tunnel release in patients 65 and
older.
Weber RA, Rude MJ.
Section of Hand Surgery, Division of Plastic Surgery, Scott & White Memorial
Hospital, 2401 South 31st Street, Temple, TX 76508, USA.
PURPOSE: Some hand surgeons have encountered an attitude among referring
physicians as well as patients that carpal tunnel release (CTR) is less
effective and more morbid in older patients. The purpose of this study was to
determine the efficacy of CTR in patients aged 65 and older. METHODS: Patients
65 years of age or older with carpal tunnel syndrome for whom release was
indicated were studied prospectively. All patients had a limited palmar incision
CTR and a standardized postoperative rehabilitation protocol. The patients'
subjective and objective signs and symptoms were measured before surgery and at
6 months after surgery. Scar tenderness and patient satisfaction also were
recorded. The Michigan Hand Outcome Questionnaire was used to determine overall
hand function, activities of daily living, work performance, pain, aesthetics,
and satisfaction with hand function. RESULTS: Seventy-five patients (105 hands)
were enrolled; 6-month follow-up data were available on 92 hands on 66 patients.
The mean age was 74 +/- 6 years. By patient report, paresthesias, numbness, day
pain, night pain, and nocturnal numbness each decreased significantly from
severe or very severe to mild or none. All but 2 of the Tinel's signs and one of
the Phalen's signs became negative. The mean 2-point discrimination improved
from 6.4 +/- 1.3 mm to 4.9 +/- 1.1 mm. Grip and pinch strength increased by 0.9
+/- 7.4 kgf and 0.6 +/- 2.5 kgf, respectively. The Michigan Hand Outcome
Questionnaire confirmed a significant improvement in overall hand function,
activities of daily living, pain, and satisfaction with hand function. Overall
83% of patients were either very or completely satisfied with their results.
CONCLUSIONS: Patients 65 years of age or older objectively benefit and have
improved clinical outcomes after CTR. Age alone should not be a contraindication
to CTR.
-----
BMC Musculoskelet Disord. 2005 Jan 18;6(1):2.
Randomized clinical trial of surgery versus conservative therapy
for carpal tunnel syndrome [ISRCTN84286481].
Martin BI, Levenson LM, Hollingworth W, Kliot M, Heagerty PJ, Turner JA, Jarvik
JG.
Department of Medicine, Division of General Internal Medicine, Multidisciplinary
Clinical Research Center, Box 359736, 325 Ninth Ave. Seattle, Washington 98104,
USA. bim@u.washington.edu <bim@u.washington.edu>
BACKGROUND: Conservative treatment remains the standard of care for treating
mild to moderate carpal tunnel syndrome despite a small number of
well-controlled studies and limited objective evidence to support current
treatment options. There is an increasing interest in the usefulness of wrist
magnetic resonance imaging could play in predicting who will benefit for various
treatments. METHOD AND DESIGN: Two hundred patients with mild to moderate
symptoms will be recruited over 3 1/2 years from neurological surgery, primary
care, electrodiagnostic clinics. We will exclude patients with clinical or
electrodiagnostic evidence of denervation or thenar muscle atrophy.We will
randomly assign patients to either a well-defined conservative care protocol or
surgery. The conservative care treatment will include visits with a hand
therapist, exercises, a self-care booklet, work modification/ activity
restriction, B6 therapy, ultrasound and possible steroid injections. The
surgical care would be left up to the surgeon (endoscopic vs. open) with usual
and customary follow-up. All patients will receive a wrist MRI at
baseline.Patients will be contacted at 3, 6, 9 and 12 months after randomization
to complete the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ). In
addition, we will compare disability (activity and work days lost) and general
well being as measured by the SF-36 version II. We will control for demographics
and use psychological measures (SCL-90 somatization and depression scales) as
well as EDS and MRI predictors of outcomes. DISCUSSION: We have designed a
randomized controlled trial which will assess the effectiveness of surgery for
patients with mild to moderate carpal tunnel syndrome. An important secondary
goal is to study the ability of MRI to predict patient outcomes.
-----
Arch Phys Med Rehabil. 2005 Jan;86(1):1-7.
Randomized controlled trial of nocturnal splinting for active
workers with symptoms of carpal tunnel syndrome.
Werner RA, Franzblau A, Gell N.
Department of Physical Medicine and Rehabilitation, University of Michigan
Health System, Ann Arbor, MI 48105, USA. rawerner@umich.edu
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.
-----
Ann Plast Surg. 2005 Jan;54(1):15-9.
Consecutive versus simultaneous bilateral carpal tunnel release.
Weber RA, Boyer KM.
Department of Surgery, Division of Plastic Surgery, Scott and White Memorial
Hospital, Scott, Sherwood and Brindley Foundation, 2401 South 31st Street,
Temple, TX, USA. rweber@swmail.sw.org
Many patients have symptoms of bilateral carpal tunnel syndrome and require
surgical release of both hands. Despite the intuitive savings to both the
patient and the institution of simultaneous carpal tunnel release, many surgeons
choose to repair one hand at a time under the assumption that the morbidity and
disability following surgery, such as pain and hand incapacity, would be too
great if both hands were repaired simultaneously. We reviewed the charts of 108
patients who underwent bilateral carpal tunnel release to ascertain information
on both the relative costs and morbidities of the 2 approaches; mean follow-up
time was 2.6 years. With regard to costs, the average number of clinic visits
for the simultaneous group was 2 versus 4.5 for the consecutive group (P <
0.0001). The mean total operating room time for the simultaneous group was 48.5
minutes versus 72.5 minutes for the consecutive group (P < 0.0001). The average
time off work for the simultaneous group was 3.25 weeks versus 6 weeks for the
consecutive group (P = 0.08). To evaluate morbidity, 62 patients consented to
telephone interviews regarding the outcome of their surgery, 51 of whom had
undergone simultaneous release. Of the 51 patients who underwent simultaneous
release, 48 (94%) were satisfied with the overall results of their surgery, and
38 (75%) stated that they would undergo simultaneous release again. All 11
patients in the consecutive group were satisfied with the results of their
surgery and would do it again (P = 0.21 and 0.03, respectively). On the basis of
these findings, we conclude first, the overall costs associated with
simultaneous release are considerably less than consecutive bilateral release,
and second, the disability following simultaneous bilateral carpal tunnel
release is no greater than that following consecutive bilateral release. We,
therefore, recommend simultaneous bilateral carpal tunnel release in patients
who have bilateral carpal tunnel syndrome.
-----
Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2004 Dec;26(6):657-60.
[Comparison of endoscopic versus open surgical treatment of
carpal tunnel syndrome]
[Article in Chinese]
Zhao H, Zhao Y, Tian Y, Yang B, Qiu GX.
Department of Orthopedic Surgery, PUMC Hospital, CAMS and PUMC, Beijing 100730,
China. zhaoh@csc.pumch.ac.cn
OBJECTIVE: To compare the results of endoscopic surgical decompression of carpal
tunnel release (CTR) with open CTR in patients with idiopathic carpal tunnel
syndrome (CTS). METHODS: Forty patients with CTS were randomly chosen for a
prospective study from April 2000 to August 2002. Endoscopic CTR was performed
in 23 CTS patients (26 sides) and open CTR was performed in 17 CTS patients (21
sides). Five parameters were evaluated, including each patient's symptom
amelioration, complication, operation time, hospitalization time, and the time
needed to resume normal lifestyle. The mean follow-up time was 2 years. RESULTS:
No significant difference was observed between the endoscopic CTR group and open
CTR group in regard to symptom amelioration, electromyographic testing, and
complications. In comparison to open CTR, endoscopic CTR significantly decreased
operation time, hospitalization time, and the time needed to resume normal
lifestyle and activity (P < 0.01). CONCLUSION: Compared with open CTR,
endoscopic CTR has the advantage of reduced pain of scar and shortened time of
hospitalization and recovery. It is a safe and effective method for treating
idiopathic CTS.
-----
Plast Reconstr Surg. 2005 Jan;115(1):163-71.
Microvascular omental transfer for the treatment of severe
recurrent median neuritis of the wrist: a long-term follow-up.
Goitz RJ, Steichen JB.
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center,
Pittsburgh, Pa 15213, USA. goitzrj@upmc.edu
The results of reoperation for recurrent carpal tunnel syndrome have been quite
disappointing. In addition to a secondary external or internal neurolysis,
multiple tissues and procedures have been used to decrease scar adherence of the
reoperated median nerve including muscle, fascial or fat flaps, and vein
wrapping. However, each technique has certain limitations, especially in the
carpal tunnel that has previously undergone multiple operations, with diffuse
scar and adherence over an extended length of the median nerve. The purpose of
this study was to evaluate the long-term functional and symptomatic outcome
following microvascular omental transfer for severe recalcitrant median
neuritis. Between 1989 and 1993, 10 extremities in seven patients underwent
omental transfer for severe recurrent median neuritis at the wrist. Nine
extremities in six women were available for personal evaluation at an average
follow-up of 6.6 years (range, 4.5 to 8.75 years). All extremities had undergone
a minimum of two previous surgical procedures, and since 1991, all patients also
failed local pedicle tissue coverage. Each patient completed a physical
examination, a questionnaire, and electrophysiologic studies. At surgery, all
median nerves were encased in dense adherent scar, which often extended proximal
to the wrist crease. There were seven neural abnormalities in six extremities,
three patent median arteries, and one aberrant palmaris longus muscle. The
Functional Status Index was 3.1 +/- 0.7 and the Symptom Severity Index was 3.1
+/- 0.9, with a range of 1 (best) to 5. Most symptoms were improved but not
completely alleviated. Four of nine extremities exhibited improved two-point
discrimination and five of seven improved sensitivity, according to the
Semmes-Weinstein monofilament test. Grip strength increased an average of 73
percent in seven of nine extremities and pinch strength increased 101 percent in
four of nine extremities. Five of six patients were satisfied with their results
and reported improved quality of life. Preoperatively, five of seven patients
were working on light duty; postoperatively, three of six patients attempted to
return to work, but none were working at final follow-up. Electrophysiologic
data did not correlate with the symptomatic or functional outcome. There were
four complications; three were related to delayed wound healing, and one
morbidly obese patient developed a ventral hernia. Wrapping the median nerve
with vascularized omentum is a viable option for the treatment of severe
recalcitrant carpal tunnel syndrome. Despite a high satisfaction rate and
significant symptomatic improvement, many symptoms will persist, but to a lesser
degree.
-----
Ann Plast Surg. 2005 Jan;54(1):15-9.
Consecutive versus simultaneous bilateral carpal tunnel release.
Weber RA, Boyer KM.
>From the Department of Surgery, Division of Plastic Surgery, Scott and White
Memorial Hospital, Scott, Sherwood and Brindley Foundation; and The Texas A&M
University System Health Science Center College of Medicine, Temple, TX.
Many patients have symptoms of bilateral carpal tunnel syndrome and require
surgical release of both hands. Despite the intuitive savings to both the
patient and the institution of simultaneous carpal tunnel release, many surgeons
choose to repair one hand at a time under the assumption that the morbidity and
disability following surgery, such as pain and hand incapacity, would be too
great if both hands were repaired simultaneously. We reviewed the charts of 108
patients who underwent bilateral carpal tunnel release to ascertain information
on both the relative costs and morbidities of the 2 approaches; mean follow-up
time was 2.6 years. With regard to costs, the average number of clinic visits
for the simultaneous group was 2 versus 4.5 for the consecutive group (P <
0.0001). The mean total operating room time for the simultaneous group was 48.5
minutes versus 72.5 minutes for the consecutive group (P < 0.0001). The average
time off work for the simultaneous group was 3.25 weeks versus 6 weeks for the
consecutive group (P = 0.08). To evaluate morbidity, 62 patients consented to
telephone interviews regarding the outcome of their surgery, 51 of whom had
undergone simultaneous release. Of the 51 patients who underwent simultaneous
release, 48 (94%) were satisfied with the overall results of their surgery, and
38 (75%) stated that they would undergo simultaneous release again. All 11
patients in the consecutive group were satisfied with the results of their
surgery and would do it again (P = 0.21 and 0.03, respectively). On the basis of
these findings, we conclude first, the overall costs associated with
simultaneous release are considerably less than consecutive bilateral release,
and second, the disability following simultaneous bilateral carpal tunnel
release is no greater than that following consecutive bilateral release. We,
therefore, recommend simultaneous bilateral carpal tunnel release in patients
who have bilateral carpal tunnel syndrome.
-----
Minim Invasive Neurosurg. 2004 Oct;47(5):261-5.
Surgical outcome of endoscopic carpal tunnel release in 100
patients with carpal tunnel syndrome.
Park SH, Cho BH, Ryu KS, Cho BM, Oh SM, Park DS.
Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University
College of Medicine, #445 Gil-dong, Gangdong-gu, Seoul 134-701, Korea. sehyuck@hallym.or.kr
The purpose of this study is to present the surgical outcome of endoscopic
carpal tunnel release (ECTR) for the treatment of carpal tunnel syndrome (CTS).
One hundred and thirty-one procedures (36 right hands, 33 left hands and 31
bilateral hands) of single portal ECTR were performed upon 100 patients (age
range: 36-77 years, mean age: 52.9 years; 98 women and 2 men) with
electrodiagnostically proven CTS for 2.5 years from 2001. Preoperative clinical
severity and results of electrodiagnostic studies were compared with surgical
outcomes at the minimal 3-month postoperative period. Among 131 cases 125 (95.4
%) with complete or significant relief of symptoms were satisfied and 6 (4.6 %)
with partial or no relief of symptoms were dissatisfied. There were 2 cases of
major complications (one with ulnar nerve injury and the other with ulnar artery
injury) that developed in our early experience of ECTR and 1 case of recurrence.
The grade of electrodiagnostic abnormalities was associated with surgical
outcome but there was no statistical significance between them. The severity of
clinical findings, age at onset and symptom duration were not correlated with
surgical outcome. In conclusion, ECTR surgery was effective in relieving the
symptoms of CTS with a low complication rate after the learning curve period.
Thus, ECTR can be an alternative to the traditional open surgery and can be the
first procedure for CTS with several advantages over open methods.
-----
J Orthop Sports Phys Ther. 2004 Oct;34(10):589-600.
Conservative interventions for carpal tunnel syndrome.
Michlovitz SL.
Temple University, Philadelphia, PA 19140, USA. Susan.Michlovitz@temple.edu
The assessment and conservative interventions in patients with carpal tunnel
syndrome (CTS) are described in this paper. Information about surgical
procedures and postoperative care has also been included. It is difficult to
make definitive conclusions about the literature regarding success of treatment
for CTS due to variations in outcome measures, severity of CTS, and
inconsistencies in duration, dosage, and follow-up time for interventions. Based
on what is known to date, this author recommends that patients with mild or
moderate CTS be provided with a conservative program of splinting the wrist in
neutral for nocturnal wear. In addition, intermittent exercise (nerve-gliding
exercises) and activity modification, including avoidance of protracted periods
of sustained gripping activities and awkward wrist positions, can be useful.
This conservative program may be complemented by pain-relieving modalities
during times of activity and supplemental participation in other exercise such
as yoga. If symptoms are not relieved to the satisfaction of the patient, or
they recur, then it is incumbent upon the therapist to refer the patient to a
hand surgeon for injection or possible surgical decompression.
-----
Harefuah. 2004 Oct;143(10):743-8, 765, 764.
[Carpal tunnel syndrome]
[Article in Hebrew]
Pritsch T, Rosenblatt Y, Carmel A.
Department of Orthopedic Surgery B, Tel Aviv Sourasky Medical Center, Israel.
Carpal tunnel syndrome is the most common peripheral nerve compression syndrome.
Compression of the median nerve in the carpal tunnel, disrupts the blood-nerve
barrier causing edema, inflammation and fibrosis of its surrounding connective
tissues. In the next stage of the syndrome there is a disruption of the myelin
coverage of the nerve followed by damage to the axons. Most carpal tunnel
syndromes are idiopathic. Other causes include intrinsic factors (which cause
pressure within the tunnel), extrinsic factors (which cause pressure from
outside the tunnel) and overuse/exertional factors. Patients usually report
numbness and pain of the palmar aspect of their 1st, 2nd, 3rd and radial half of
their 4th finger, night pain and gradual worsening of their symptoms. At a later
stage, weakness and atrophy of the thenar muscles appears. The physical
examination may show a decrease in sensibility, positive provocative tests and a
decrease in thenar strength. The typical finding in the nerve conduction tests
is a prolonged latency period. The conservative treatment for carpal tunnel
syndrome includes ergonomic modifications, anti inflammatory medications and
splintage and less frequently, special exercise and therapeutic ultrasound. The
indications for operative treatment are failure of conservative treatment or
severe carpal tunnel syndrome. The purpose of the operation is to relieve the
pressure in the carpal tunnel by dissecting the transverse ligament. The
operation can be done in an open approach, endoscopic approach or limited
invasive approach.
-----
Wien Klin Wochenschr. 2004;116 Suppl 2:24-7.
Clinical versus electrodiagnostic effectiveness of splinting in
the conservative treatment of carpal-tunnel syndrome.
Papez BJ, Turk Z.
Department for Medical Rehabilitation, Maribor Teaching Hospital, Maribor,
Slovenia. breda.jesensek@sb-mb.si
BACKGROUND: Splinting is known as one of the most effective non-aggressive
treatments for carpal-tunnel syndrome (CTS). Early and accurate diagnosis of CTS
is critical for effective non-surgical management. Nerve-conduction studies
confirm the diagnosis of CTS with a high degree of sensitivity and specificity.
Many patients report that their symptoms decrease after splinting; consequently,
improved electrophysiological findings are expected. OBJECTIVE: The aim of the
study was to evaluate the clinical and neurophysiological effectiveness of
splinting in patients with CTS. METHODS: In a prospective study of 77 hands with
CTS symptoms, neurophysiological tests were performed before and after 12 weeks
of using a splint. A custom-made volar thermoplastic wrist splint was fabricated
in a neutral wrist position to maximize carpal-tunnel space and minimize the
compressive forces on the median nerve. Each patient was provided with a
custom-made splint, and was asked to wear it during sleep and whenever possible
when awake. The case history was taken, and a physical examination and repeated
nerve conduction studies were performed at the start and after 12 weeks. Data
were analysed statistically. RESULTS: We calculated the mean and the range for
each electrophysiological test before and after 12 weeks of splint use. There
was no significant difference between pre- and post-measurement of each
parameter (p > 0.05). Good relief of symptoms occurred soon after the patients
began wearing the splint; however, the electrodiagnostic test remained
pathological. CONCLUSION: Even though immobilization (wrist splint in neutral
position) does not affect the common electrodiagnostic parameters in CTS
diagnostics, it caused the disappearance of clinical symptoms in 75% of the
patients. There is therefore a need for further research regarding the
usefulness of repeated electrodiagnostic studies.
-----
Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003905.
Surgical treatment options for carpal tunnel syndrome.
Scholten R, Gerritsen A, Uitdehaag B, Geldere D, Vet H, Bouter L.
Dutch Cochrane Centre, PO Box 22700, Amsterdam, NETHERLANDS, 1100 DE.
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 and/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 2003. We conducted
computer-aided searches of the trials register of the Cochrane Neuromuscular
Disease Group (searched in July 2003), the Cochrane Central Register of
Controlled Trials (TheCochrane Library, Issue 2, 2003), MEDLINE (January 1966 to
August 2003), EMBASE (January 1980 to August 2003) and 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 reviewers performed study selection, assessment of
methodological quality and data abstraction independently of each other. MAIN
RESULTS: Twenty-three studies were included in the review. The methodological
quality of the trials was fair to good. However, the application of allocation
concealment was mentioned explicitly in only one trial. 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 seem to offer better relief from symptoms in the short- or
long-term. There was conflicting evidence about whether endoscopic carpal tunnel
release resulted in earlier return to work and/or activities of daily living
than open carpal tunnel release. REVIEWERS' 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.
-----
Aust J Physiother. 2004;50(3):147-51.
Ultrasound and laser therapy in the treatment of carpal tunnel
syndrome.
Bakhtiary AH, Rashidy-Pour A.
Rehabilitation Faculty, Semnan Medical Sciences University, Senman, Iran.
amir822@yahoo.com.
This study was designed to compare the efficacy of ultrasound and laser
treatment for mild to moderate idiopathic carpal tunnel syndrome. Ninety hands
in 50 consecutive patients with carpal tunnel syndrome confirmed by
electromyography were allocated randomly in two experimental groups. One group
received ultrasound therapy and the other group received low level laser
therapy. Ultrasound treatment (1 MHz, 1.0 W/cm(2), pulse 1:4, 15 min/session)
and low level laser therapy (9 joules, 830 nm infrared laser at five points)
were applied to the carpal tunnel for 15 daily treatment sessions (5
sessions/week). Measurements were performed before and after treatment and at
follow up four weeks later, and included pain assessment by visual analogue
scale; electroneurographic measurement (motor and sensory latency, motor and
sensory action potential amplitude); and pinch and grip strength. Improvement
was significantly more pronounced in the ultrasound group than in low level
laser therapy group for motor latency (mean difference 0.8 m/s, 95% CI 0.6 to
1.0), motor action potential amplitude (2.0 mV, 95% CI 0.9 to 3.1), finger pinch
strength (6.7 N, 95% CI 5.0 to 8.2), and pain relief (3.1 points on a 10-point
scale, 95% CI 2.5 to 3.7). Effects were sustained in the follow-up period.
Ultrasound treatment was more effective than laser therapy for treatment of
carpal tunnel syndrome. Further study is needed to investigate the combination
therapy effects of these treatments in carpal tunnel syndrome patients.
-----
Arch Phys Med Rehabil. 2004 Sep;85(9):1409-16.
Continuous low-level heat wrap therapy is effective for treating
wrist pain.
Michlovitz S, Hun L, Erasala GN, Hengehold DA, Weingand KW.
Department of Physical Therapy, Temple University, Philadelphia, PA 19140, USA.
susan.michlovitz@temple.edu
OBJECTIVE: To evaluate the efficacy of continuous low-level heat wrap therapy
for the treatment of various sources of wrist pain including strain and sprain
(SS), tendinosis (T), osteoarthritis (OA), and carpal tunnel syndrome (CTS).
DESIGN: Prospective, randomized, parallel, single-blind (investigator),
placebo-controlled, multicenter clinical trial. SETTING: Two community-based
research facilities. PARTICIPANTS: Ninety-three patients (age range, 18-65 y)
with wrist pain. INTERVENTION: Subjects with moderate or greater wrist pain were
randomized and stratified to 1 of the following treatments: efficacy evaluation
(heat wrap, n=39; oral placebo, n=42) or blinding (oral acetaminophen, n=6;
unheated wrap, n=6). Data were recorded over 3 days of treatment and 2 days of
follow-up. MAIN OUTCOME MEASURES: The primary comparison was between the heat
wrap and the oral placebo group among SS/T/OA subjects for pain relief. Outcome
measures included pain relief (0-5 scale), joint stiffness (101-point numeric
rating scale), grip strength measured by dynamometry, and perceived pain and
disability (Patient Rated Wrist Evaluation [PRWE]); subjects with CTS also
completed the Symptom Severity Scale and Functional Status Scale. RESULTS: Heat
wrap therapy showed significant benefits in day 1 to 3 mean pain relief (P=.045)
and increased day 3 grip strength (P=.02) versus oral placebo for the SS/T/OA
group. However, joint stiffness and PRWE results were comparable between the 2
treatments. For the CTS group, heat wraps provided greater day 1 to 3/hour 0 to
8 mean pain relief (P=.001), day 1 to 3 mean joint stiffness reduction (P=.004),
increased day 3 grip strength (P=.003), reduced PRWE scores (P=.0015), reduced
symptom severity (P=.001), and improved functional status (P=.04). In addition,
the heat wrap showed significant extended benefits through follow-up (day 5) in
the CTS group. CONCLUSIONS: Continuous low-level heat wrap therapy was
efficacious for the treatment of common conditions causing wrist pain and
impairment.
-----
J Peripher Nerv Syst. 2004 Sep;9(3):168-76.
Carpal tunnel syndrome in elderly patients: results of surgical
decompression.
Mondelli M, Padua L, Reale F.
EMG service,ASL 7, Siena, Italy.
Abstract This study prospectively compared preoperative and postoperative (6
months after surgical release) clinical and electrophysiological evaluation and
self-administered Boston questionnaire (BQ) findings of a series of elderly
carpal tunnel syndrome (CTS) patients with those of young and adult patients.
Three hundred twenty three consecutive hands (282 patients) underwent surgery
between 1997 and 2000. Patients were divided into four age groups: group 1
(20-40 years), 49 hands; group 2 (41-54 years), 96 hands; group 3 (55-69 years),
106 hands; and group 4 (70-90 years), 72 hands. Sex ratio, education, duration
and bilaterality of CTS, history of wrist and hand trauma, connective tissue and
thyroid diseases, diabetes, polyneuropathy, renal failure, and other nerve
entrapment syndromes were recorded. The elderly group (group 4) only had more
cases of diabetes than groups 1 and 2 (young and adult patients). Before
surgery, elderly patients showed more severe clinical objective and
electrophysiological findings than young and adult patients. Preoperative
subjective findings (BQ scores) were similar in all four groups. Although their
absolute postoperative BQ scores and clinical objective and electrophysiological
stages improved, elderly patients showed less improvement in all findings than
the 20-54 age groups, presumably due to greater preoperative damage and less
repair capacity of the compressed nerve. This, however, is not a
contraindication for surgical release in elderly patients.
-----
Muscle Nerve. 2004 Aug;30(2):182-7.
Double-blind randomized controlled trial of low-level laser
therapy in carpal tunnel syndrome.
Irvine J, Chong SL, Amirjani N, Chan KM.
Division of Physical Medicine and Rehabilitation, University of Alberta,
Edmonton, Alberta, Canada.
Several studies have suggested that low-level laser therapy (LLLT) is effective
in patients with carpal tunnel syndrome (CTS). In a double-blind randomized
controlled trial of LLLT, 15 CTS patients, 34 to 67 years of age, were randomly
assigned to either the control group (n = 8) or treatment group (n =7). Both
groups were treated three times per week for 5 weeks. Those in the treatment
group received 860 nm galium/aluminum/arsenide laser at a dosage of 6 J/cm2 over
the carpal tunnel, whereas those in the control group were treated with sham
laser. The primary outcome measure was the Levine Carpal Tunnel Syndrome
Questionnaire, and the secondary outcome measures were electrophysiological data
and the Purdue pegboard test. All patients completed the study without adverse
effects. There was a significant symptomatic improvement in both the control (P
= 0.034) and treatment (P =0.043) groups. However, there was no significant
difference in any of the outcome measures between the two groups. Thus, LLLT is
no more effective in the reduction of symptoms of CTS than is sham treatment.
-----
J Hand Surg [Br]. 2004 Aug;29(4):390-2.
Effect of wrist position on power grip and key pinch strength
following carpal tunnel decompression.
Mathur K, Pynsent PB, Vohra SB, Thomas B, Deshmukh SC.
Royal Orthopaedic Hospital, Birmingham, UK, Department of Hand and Upper Limb
Surgery, City Hospital, Dudley Road, Birmingham, UK and University of
Birmingham, UK.
Power grip and thumb key pinch strength were measured pre- and immediately
postoperatively in 30 patients with carpal tunnel syndrome while the wrist was
in flexion and extension. The carpal tunnel decompression was performed under
local infiltration with 1% lignocaine. Grip strength decreased more in wrist
flexion than in wrist extension. No difference was found in thumb pinch
strength. The authors conclude that some of the immediate postoperative loss of
grip strength in wrist flexion can be attributed to prolapse of flexor tendons
out of the carpal tunnel in this position.
-----
J Hand Surg [Br]. 2004 Aug;29(4):329-33.
Carpal tunnel syndrome and work.
Dias JJ, Burke FD, Wildin CJ, Heras-Palou C, Bradley MJ.
Pulvertaft Hand Centre, Derbyshire Royal Infirmary, London Road Derby, UK.
The incidence, age at presentation, disability and outcome after surgery were
investigated in 327 consecutive women of working age presenting to a hand unit
with carpal tunnel syndrome. Two hundred and seventeen were working, 55 of these
in repetitive occupations. One hundred and ten were not in employment. All three
groups had similar mean ages (around 46 years). On a population basis more women
in non-repetitive occupations presented with carpal tunnel syndrome
(220/100,000/year) than those in repetitive work (122/100,000/year) or those not
working (129/100,000/year), and more were offered surgery (82% versus 67% for
those in repetitive work and 58% for those not working). However, symptoms and
disability; as assessed with the Michigan Hand Questionnaire and the SF-12, were
less severe in working women. This study suggests that working in repetitive or
non-repetitive occupations does not cause, aggravate or accelerate carpal tunnel
syndrome. Working women may struggle to accommodate their symptoms compared to
women who are not in employment causing more to seek help.
-----
Neurol Sci. 2004 Jun;25(2):48-52.
Long-term effectiveness of steroid injections and splinting in
mild and moderate carpal tunnel syndrome.
Sevim S, Dogu O, Camdeviren H, Kaleagasi H, Aral M, Arslan E, Milcan A.
Department of Neurology, Faculty of Medicine, Mersin University, Noroloji
Anabilim Dali, 33070 Mersin, Turkey. serhansevim@mail.koc.net
To evaluate the long-term efficacy of non-surgical treatment methods for mild
and moderate carpal tunnel syndrome, 120 patients with clinical symptoms and
electrophysiologic evidence were included in a prospective, randomized and
blinded trial: 60 patients were instructed to wear splints every night, 30
received injections of betamethasone 4 cm proximal to the carpal tunnel, and 30
received injections distal to the carpal tunnel. After approximately 1 year
(mean, 11 months; range, 9-14), 108 patients were available for final
evaluation. We assessed clinical symptom severity and performed detailed
electrophysiologic examinations before and after treatment. Splinting provided
symptomatic relief and improved sensory and motor nerve conduction velocities at
the long-term follow-up when the splints were worn almost every night. Proximal
and distal injections of steroids were ineffective on the basis of both clinical
symptoms and electrophysiologic findings.
-----
J Hand Surg [Br]. 2004 Jun;29(3):271-6.
Carpal tunnel decompression. Is lengthening of the flexor
retinaculum better than simple division?
Dias JJ, Bhowal B, Wildin CJ, Thompson JR.
University Hospitals of Leicester, Glenfield Hospital, Groby Road, Leicester,
UK. joseph.dias@uhl-tr.nhs.uk
This prospective randomized double-blind control trial compared lengthening and
simple division of the flexor retinaculum in carpal tunnel decompression.
Twenty-six patients with bilateral carpal tunnel syndrome were randomly
allocated to have the flexor retinaculum divided on one side and lengthened on
the other. All 52 hands were reviewed at regular intervals up to 25 weeks. The
patients, therapists and the final reviewer were unaware of treatment
allocation. The Levine symptom and function scores were used to assess the
severity of the carpal tunnel syndrome and showed that the two treatments were
comparable for relief of carpal tunnel symptoms. The two treatments were also
similar for function measured with the Jebsen-Taylor test. There is no
identifiable benefit in lengthening the flexor retinaculum when decompressing
the carpal tunnel. Moderate or severe pillar and scar pain is common, occurring
in 13 of 52 hands after surgery, but only in four by the 12th week and two by
the 25th week.
-----
Plast Reconstr Surg. 2004 Jun;113(7):2020-9.
A comparison of flexor tenosynovectomy, open carpal tunnel
release, and open carpal tunnel release with flexor tenosynovectomy in the
treatment of carpal tunnel syndrome.
Ketchum LD.
Menorah Medical Center, Overland Park, Kans., USA. ldkmd5701@aol.com
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.
-----
Clin Neurophysiol. 2004 Jun;115(6):1464-8.
Clinical and electrophysiological follow-up after local steroid
injection in the carpal tunnel syndrome.
Hagebeuk EE, de Weerd AW.
Department of Clinical Neurophysiology, MCH, Westeinde Hospital, Lijnbaan 32,
2512 VA Den Haag, The Netherlands. ehagebeuk@hotmail.com
OBJECTIVE: Local steroid injections are used for treatment for the carpal tunnel
syndrome (CTS). Study of changes in neurophysiological parameters after such
treatment for idiopathic CTS might be a supportive argument for the
effectiveness of steroid treatment. METHODS: Twenty-one patients with CTS were
included and evaluated before and at 1, 3 and 6 months after treatment. At the
inclusion date patients received a single 1 ml local steroid injection. Various
electrophysiological tests were used. For clinical evaluation, we used the
Boston Carpal Tunnel Questionnaire (BCTQ) and the General Outcome Score.
RESULTS: The mean nerve conduction parameters had significantly improved at 1
month, except the SNAP4 and CMAP. This improvement was still present at 3
months. At 6 months follow-up, the improvement in the SDL4, SNAP4, M-U, DML and
CMAP remained significant. In 6 patients (29%), the nerve conduction parameters
normalized and remained so until the end of the study. The BCTQ and the General
Outcome Score significantly improved as well. However, there was no correlation
between the electrophysiological data, the BCTQ and the General Outcome Score.
CONCLUSIONS: The improvements of nerve conduction parameters independently
support the ideas on effectiveness of steroid injection therapy in CTS.
-----
Ann Fam Med. 2004 May-Jun;2(3):267-73.
What can family physicians offer patients with carpal tunnel
syndrome other than surgery? A systematic review of nonsurgical management.
Goodyear-Smith F, Arroll B.
Department of General Practice & Primary Health Care, Faculty of Medical &
Health Sciences, University of Auckland, Private Bag 92019, Auckland, New
Zealand. f.goodyear-smith@auckland.ac.nz
BACKGROUND: We undertook a literature review to produce evidence-based
recommendations for nonsurgical family physician management of carpal tunnel
syndrome (CTS). METHODS: Study design was systematic review of randomized
controlled trials (RCTs) on CTS treatment. Data sources were English
publications from all relevant databases, hand searches, and guidelines.
Outcomes measured were nonsurgical management options for CTS. RESULTS: We
assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using
historical controls. A considerable percentage of CTS resolves spontaneously.
There is strong evidence that local corticosteroid injections, and to a lesser
extent oral corticosteroids, give short-term relief for CTS sufferers. There is
limited evidence to indicate that splinting, laser-acupuncture, yoga, and
therapeutic ultrasound may be effective in the short to medium term (up to 6
months). The evidence for nerve and tendon gliding exercises is even more
tentative. The evidence does not support the use of nonsteroidal
anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic
treatment, or magnet treatment. CONCLUSIONS: For those who are not able to get
surgery or for those who do not want surgery, there are some conservative
modalities that can be tried. These modalities include ones for which there is
good evidence. It would be reasonable to try some of the techniques with less
evidence if the better ones are not successful. Reconsideration of surgery must
always be kept in mind to avoid permanent nerve damage.
-----
J Hand Surg [Am]. 2004 May;29(3):379-83.
Patient-reported outcome after carpal tunnel release for advanced
disease: a prospective and longitudinal assessment in patients older than age
70.
Leit ME, Weiser RW, Tomaino MM.
Department of Orthopaedic Surgery, University of Rochester Medical Center,
Rochester, NY, USA.
PURPOSE: Advanced stages of nerve compression are likely to result in
irreversible intraneural changes including intrinsic fibrosis and axon loss, and
advanced age is expected to compromise nerve regeneration and recovery. Although
satisfactory outcomes have been reported we hypothesized that carpal tunnel
release in an elderly population with advanced carpal tunnel disease might not
significantly improve symptom severity, functional status, or grip strength
compared with before surgery. Our purpose was to evaluate these 3 parameters
both before and after surgery to assess the efficacy of surgical intervention.
METHODS: Between October 2000 and January 2002 a total of 13 patients (14 hands)
were enrolled into a prospective longitudinal study. Entry criteria included
advanced carpal tunnel syndrome based on neurophysiologic studies (absent
sensory latencies and positive fibrillation potentials), clinical examination (thenar
atrophy), and age over 70 years. Exclusion criteria included cervical disease,
prior surgery, concomitant surgery, diabetic neuropathy, and associated cubital
tunnel syndrome. There were 7 men and 6 women with an average age of 79 years
(range, 72-90 y). With the help of a neutral observer each patient completed the
Brigham and Women's validated carpal tunnel syndrome questionnaire before and 6
and 12 months after surgery to assess symptom severity and functional status.
Grip strength was measured before and at 1 year after surgery and each patient
also was asked to rate their level of satisfaction with their outcome at 1 year
after surgery. RESULTS: Before surgery the mean symptom severity score was 29
based on a scale in which a minimum score of 11 reflects no symptoms and a
maximum score of 55 reflects severe symptoms. The mean functional status score
was 18 on a scale in which a minimum score of 8 reflects no difficulty and a
high score of 40 reflects severe impairment. Six months after surgery the mean
symptom severity score decreased from 29 to 15 (11 reflects no symptoms) and the
average functional status score decreased from 18 to 11 (8 reflects no
difficulty). One year after surgery the symptom severity score decreased from 15
to 14 and the functional status score decreased from 11 to 9. Compared with
scores before surgery the improvements at 6 months and 1 year were statistically
significant. Patient satisfaction was noted for 13 of 14 hands. Average grip
strength remained unchanged after surgery. CONCLUSIONS: Carpal tunnel release is
unlikely to result in a total elimination of symptoms and complete restoration
of function when performed in elderly patients with advanced disease. Although
grip strength did not improve at final follow-up evaluation, symptom severity
and functional status did improve from the patient's perspective. We conclude
that carpal tunnel release is efficacious in this subset of patients.
-----
J Hand Ther. 2004 Apr-Jun;17(2):210-28.
Effectiveness of hand therapy interventions in primary management
of carpal tunnel syndrome: a systematic review.
Muller M, Tsui D, Schnurr R, Biddulph-Deisroth L, Hard J, MacDermid JC.
School of Rehabilitation Science, McMaster University, Hamilton, Ontario,
Ontario, Canada.
The purpose of this study was to determine the effectiveness of hand therapy
interventions for carpal tunnel syndrome (CTS) based on the best available
evidence. A qualitative systematic review was conducted. A literature search
using 40 key terms was conducted from the earliest available date to January
2003 using seven databases. Articles were randomly assigned to two of five
reviewers and evaluated according to predetermined criteria for inclusion at
each of the title, abstract, and article levels. Included studies were
independently scored by two reviewers using a structured effectiveness quality
evaluation scale and also graded according to Sackett's Levels of Evidence.
There were 2027 articles identified from the literature search, of which 345 met
the inclusion criteria. Twenty-four studies were used to formulate 30
recommendations. Current evidence demonstrates a significant benefit (grade B
recommendations) from splinting, ultrasound, nerve gliding exercises, carpal
bone mobilization, magnetic therapy, and yoga for people with CTS.
-----
Int J Clin Pract. 2004 Apr;58(4):337-9.
Long-term outcome of carpal tunnel syndrome after conservative
treatment.
Hui AC, Wong SM, Tang A, Mok V, Hung LK, Wong KS.
Department of Medicine, Prince of Wales Hospital, The Chinese University of Hong
Kong, Shatin, New Territories, Hong Kong. cfhui@cuhk.edu.hk
The purpose of this study was to investigate the long-term prognosis of patients
with carpal tunnel syndrome (CTS). We prospectively followed-up patients with
CTS for 80 weeks. Thirty cases had been treated with a single injection of
methylprednisolone acetate and another 30 with a 10-day course of prednisolone.
At the end of the follow-up period, there were no significant differences in
symptoms as measured by global symptom score and in the proportion of patients
who progressed to decompressive surgery. Few patients who were not operated on
(11.4%) remain asymptomatic.
-----
Plast Reconstr Surg. 2004 Apr 1;113(4):1184-91.
A systematic review of reviews comparing the effectiveness of
endoscopic and open carpal tunnel decompression.
Thoma A, Veltri K, Haines T, Duku E.
Department of Surgery, Division of Plastic and Reconstructive Surgery, St.
Joseph's Healthcare, Hamilton, Ontario, Canada. athoma@mcmaster.ca
Controversy persists regarding the benefit of endoscopic carpal tunnel release
compared with open carpal tunnel release for pain, numbness, strength, return to
work and function, scar tenderness, and complications. For surgeons, a
recommended first source of information on treatment effectiveness is a review
of high-methodologic-quality articles. This review of reviews was undertaken to
answer this clinical question regarding these outcomes. Cochrane, MEDLINE,
EMBASE, CINAHL, and HealthSTAR databases were searched using the key words "endoscopic
carpal tunnel," with limits "review or overview" and dates from 1989 to present.
Five key journals were hand-searched. Any review with a reference to at least
one randomized controlled trial that compared endoscopic carpal tunnel release
to open carpal tunnel release was to be included. Two reviewers independently
scanned titles and abstracts for potential relevance. Selection as relevant was
confirmed through a review of full texts. Disagreements were resolved through
discussion and consensus. The selected reviews were assessed for methodologic
quality on the basis of the scale of Hoving et al. Of 48 articles initially
identified, seven pertinent reviews were selected. Of these seven, three reviews
of high methodologic quality concurred that there is no difference between the
two techniques in symptom relief and that the evidence is conflicting for return
to work and function. The risk of permanent median nerve injury does not differ
between the techniques. The reviews indicated that the endoscopic carpal tunnel
release technique is worse in terms of reversible nerve injury but superior in
terms of grip strength and scar tenderness, at least in short-term follow-up.
Several trials have not been incorporated in these reviews and statistical
pooling has not been conducted. Further systematic review with meta-analysis may
permit more definitive conclusions about the relative effectiveness of these two
techniques, particularly with regard to return to work and function.
-----
J Hand Surg [Br]. 2004 Apr;29(2):113-5.
A randomized controlled trial of knifelight and open carpal
tunnel release.
Bhattacharya R, Birdsall PD, Finn P, Stothard J.
Department of Trauma and Orthopaedic Surgery, Middlesbrough General Hospital,
Ayresome Green Lane, Middlesbrough, TS5 5AZ, UK.
A randomized controlled trial was done to compare the results of carpal tunnel
decompression using the standard open approach and the Knifelight technique.
Twenty-six patients with bilateral carpal tunnel syndrome requiring operation
were selected for the study and the operative technique was randomized for the
first hand. Six weeks later, the second hand was operated upon using the
alternate technique. There was little difference between the two techniques with
regard to time taken to return to work, return of grip strength, symptom relief,
complications, incidence of pillar pain and patient preference. However, the
incidence of scar tenderness was significantly lower with the Knifelight
technique.
-----
Nutr Rev. 2004 Mar;62(3):96-104.
Pyridoxine hydrochloride treatment of carpal tunnel syndrome: a
review.
Aufiero E, Stitik TP, Foye PM, Chen B.
Department of Physical Medicine and Rehabilitation, University of Medicine and
Dentistry of New Jersey, New Jersey Medical School, Newark, NJ 07103, USA.
It has been hypothesized that idiopathic carpal tunnel syndrome (CTS) is a
manifestation of vitamin B6 deficiency. Some claim that B6 supplementation can
alleviate symptoms. Others argue that pain relief occurs because of vitamin B6's
anti-nociceptive properties or because B6 supplementation addresses an
unrecognized peripheral neuropathy. Few studies on CTS and B6 employed
electrodiagnostic techniques in diagnosis, and few showed a correlation between
symptoms and improved electrodiagnostic parameters with supplementation. Other
studies failed to measure or estimate B6 levels. Nevertheless, it appears
reasonable to recommend vitamin B6 supplementation to people with CTS. Some
patients will improve symptomatically with low risks of toxicity in recommended
doses.
-----
J Hand Surg [Am]. 2004 Mar;29(2):307-17.
Carpal tunnel syndrome: cross-sectional and outcome study in
Ontario workers.
Manktelow RT, Binhammer P, Tomat LR, Bril V, Szalai JP.
University Health Network, Toronto General Hospital, 200 Elizabeth Street, Eaton
North, Toronto, Ontario 7-228, Canada.
PURPOSE: To carry out an analytic cross-sectional study of Ontario workers with
carpal tunnel syndrome (CTS) and to assess workers' symptoms, functional
disabilities, recreational difficulties, and work capability 4 years after
treatment of their CTS. METHODS: Data were obtained by review of Ontario Workers
Safety and Insurance Board (WSIB) files and by completion of self-assessment
questionnaires. Inclusion criteria included all workers registered with the
Ontario WSIB who were off work with newly diagnosed carpal tunnel syndrome in
1996. RESULTS: There are 3 million workers covered by the WSIB in the province
of Ontario. In 1996, 964 of them developed work-related CTS that required time
off for treatment. Of these patients 53% were women and 75% had bilateral CTS.
Eighty-one percent of the unilateral cases involved the dominant extremity. The
average age at the time of claim was 41 years and workers were at the same job
type for an average of 7.4 years (unilateral) and 8.5 years (bilateral),
respectively. Thirty-nine percent of workers had a history of another tendonitis
or epicondylitis. Seventy-five percent of workers had surgery and on average
returned to work 3 months later. Four years after treatment, outcome was
assessed by self-administered questionnaires, for which there was a 73% response
rate. Forty-six percent of workers experienced moderate to severe pain, 47% had
moderate to severe numbness, and 40% had difficulty grasping and using small
objects. Only 14% were symptom free. Successful return to work was considered to
be a return to the same job with or without modifications, and it occurred in
64% of cases. Better clinical outcome scores were found to occur with surgery
and abnormal nerve conduction study results. Worse clinical outcome scores were
present with repeat surgery and surgical complications. Concurrent diagnoses of
either tendonitis or epicondylitis also resulted in worse clinical outcome
scores and worse return-to-work outcomes. The average total cost in Canadian
dollars to the WSIB exceeded $13,700 per worker for a total cost in excess of
$13,200,000 per year. (In 1996, $1 Canadian = $1.365 US.) CONCLUSIONS: These
outcomes indicate that Canadian workers have a large amount of permanent pain
and suffering, a large loss of work productivity, and incur a considerable
financial cost as a result of work-related CTS.
-----
Plast Reconstr Surg. 2004 Feb;113(2):550-6.
A prospective study to assess the outcome of steroid injections
and wrist splinting for the treatment of carpal tunnel syndrome.
Graham RG, Hudson DA, Solomons M, Singer M.
Martin Singer Hand unit, Groote Schuur Hospital, University of Cape Town, South
Africa. rgraham@uctgsh1.uct.ac.za
Surgery is the definitive treatment for carpal tunnel syndrome. Conservative
treatments, such as wrist splinting and steroid injections, are also effective
for the relief of carpal tunnel symptoms, but their use remains controversial
because they only offer long-term relief in a minority of patients. A
prospective study was performed to assess the role of steroid injections
combined with wrist splinting for the management of carpal tunnel syndrome. A
total of 73 patients with 99 affected hands were studied. Patients presenting
with known medical causes or muscle wasting were excluded. Diagnosis was made
clinically and electrodiagnostic studies were performed only when equivocal
clinical signs were present. Each patient received up to three betamethasone
injections into the carpal tunnel and wore a neutral-position wrist splint
continuously for 9 weeks. After that period, symptomatic patients received an
open carpal tunnel release, and those who remained asymptomatic were followed up
regularly for at least 1 year. Patients who relapsed were scheduled for surgery.
At a minimum follow-up of 1 year, seven patients (9.6 percent) with 10 affected
hands (10.1 percent) remained asymptomatic. This group had a significantly
shorter duration of symptoms (2.9 months versus 8.35 months; p = 0.039,
Mann-Whitney test) and significantly less sensory change (40 percent versus 72
percent; p = 0.048, Fisher's exact test) at presentation when compared with the
group who had surgery. It is concluded that steroid injections and wrist
splinting are effective for relief of carpal tunnel syndrome symptoms but have a
long-term effect in only 10 percent of patients. Symptom duration of less than 3
months and absence of sensory impairment at presentation were predictive of a
lasting response to conservative treatment. It is suggested that selected
patients (i.e., with no thenar wasting or obvious underlying cause) presenting
with mild to moderate carpal tunnel syndrome receive either a single steroid
injection or wear a wrist splint for 3 weeks. This will allow identification of
the 10 percent of patients who respond well to conservative therapy and do not
need surgery.
-----
Muscle Nerve. 2004 Jan;29(1):82-8.
Intracarpal steroid injection is safe and effective for
short-term management of carpal tunnel syndrome.
Armstrong T, Devor W, Borschel L, Contreras R.
Department of Neurology, Kaiser Permanente, 4405 Vandever Avenue, San Diego,
California 92120, USA. timothy.p.armstrong@kp.org
A double-blinded placebo-controlled trial was performed to evaluate the use of
steroid injections beneath the transverse carpal ligament in the treatment of
carpal tunnel syndrome (CTS) refractory to nonsurgical therapy. Forty-three
patients received 6 mg betamethasone and lidocaine and 38 patients received 1 ml
saline placebo and lidocaine. The primary outcome measure was satisfaction with
symptom relief. Thirty patients (70%) in the steroid-treated group were
satisfied or highly satisfied compared with 13 (34%) of placebo-treated patients
(P < 0.001). Patients receiving steroids also showed significant improvement in
median nerve conduction parameters and scores on validated symptom/function
questionnaires. Forty-six patients were treated with serial injections for
recurrent CTS symptoms. After 18 months, 17 patients reported adequate symptom
relief with steroid injection, and 18 patients with unsatisfactory symptom
relief were referred for carpal tunnel release surgery. We conclude that
although steroid injections are safe and effective for temporary relief of CTS,
most patients will eventually require surgery for long-term control of their
symptoms.
-----
J Hand Surg [Br]. 2004 Apr;29(2):113-5.
A randomized controlled trial of knifelight and
open carpal tunnel release.
Bhattacharya R, Birdsall PD, Finn P, Stothard J.
Department of Trauma and Orthopaedic Surgery, Middlesbrough General
Hospital, Ayresome Green Lane, Middlesbrough, TS5 5AZ, UK.
A randomized controlled trial was done to compare the results
of carpal tunnel decompression using the standard open approach
and the Knifelight((R)) technique. Twenty-six patients with bilateral
carpal tunnel syndrome requiring operation were selected for the
study and the operative technique was randomized for the first
hand. Six weeks later, the second hand was operated upon using
the alternate technique. There was little difference between the
two techniques with regard to time taken to return to work, return
of grip strength, symptom relief, complications, incidence of
pillar pain and patient preference. However, the incidence of
scar tenderness was significantly lower with the Knifelight((R))
technique.
-----
Cochrane Database Syst Rev. 2004;1:CD003471.
Ergonomic and physiotherapeutic interventions
for treating upper extremity work related
disorders in adults.
Verhagen A, Bierma-Zeinstra S, Feleus A, Karels C, Dahaghin
S, Burdorf L, Vet H, Koes B.
Department of General Practice, Erasmus MC, P.O. Box 1738, 3000
DR Rotterdam, NETHERLANDS.
BACKGROUND: Conservative interventions such as physiotherapy
and ergonomic adjustments play a major part in the treatment of
most work-related musculoskeletal disorders (WRMD). OBJECTIVES:
The objective of this systematic review is to determine whether
conservative interventions have a significant impact on short
and long-term outcomes for upper extremity WRMD in adults. SEARCH
STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group
specialised register (January 2002) and Cochrane Rehabilitation
and Related Therapies Field specialised register (January 2002),
the Cochrane Controlled Trials Register (The Cochrane Library
Issue 3, 2001), PubMed (1966 to November 2001), EMBASE (1988 to
November 2001), and CINAHL (1982 to November 2001). We also searched
the Physiotherapy Index (1988 to November 2001) and reference
lists of articles. No language restrictions were applied. SELECTION
CRITERIA: Only randomised controlled trials and concurrent controlled
trials studying conservative interventions for adults suffering
from upper extremity WRMD were included. Conservative interventions
may include exercises, relaxation, physical applications, biofeedback,
myofeedback and work place adjustments. DATA COLLECTION AND ANALYSIS:
Two reviewers independently selected the trials from the search
yield and assessed the clinical relevance and methodological quality
using the Delphi list. In the event of clinical heterogeneity
or lack of data we used a rating system to assess levels of evidence.
MAIN RESULTS: We included 15 trials involving 925 people. Twelve
trials included people with chronic non-specific neck or shoulder
complaints, or non-specific upper extremity disorders. Over 20
interventions were evaluated; seven main subgroups of interventions
could be determined: exercises, manual therapy, massage, ergonomics,
multidisciplinary treatment, energised splint and individual treatment
versus group therapy. Overall, the quality of the studies appeared
to be poor. In 10 studies a form of exercise was evaluated, and
there is limited evidence about the effectiveness of exercises
only when compared to no treatment. Concerning manual therapy
(1 study), massage (4 studies), multidisciplinary treatment (1
study) and energised splint (1 study) no conclusions can be drawn.
Limited evidence is found concerning the effectiveness of specific
keyboards for patients with carpal tunnel syndrome. REVIEWER'S
CONCLUSIONS: This review shows limited evidence for the effectiveness
of keyboards with an alternative force-displacement of the keys
or an alternative geometry, and limited evidence for the effectiveness
of individual exercises. The benefit of expensive ergonomic interventions
(such as new chairs, new desks etc) in the workplace is not clearly
demonstrated.
-----
Cochrane Database Syst Rev. 2003;(1):CD003219
Non-surgical treatment (other than steroid injection)
for carpal tunnel syndrome.
O'Connor D, Marshall S, Massy-Westropp N.
School of Occupational Therapy, University of South Australia,
City East Campus, North Terrace, Adelaide, South Australia, Australia.
Denise.OConnor@unisa.edu.au
BACKGROUND: Non-surgical treatment for carpal tunnel syndrome
is frequently offered to those with mild to moderate symptoms.
The effectiveness and duration of benefit from non-surgical treatment
for carpal tunnel syndrome remain unknown. OBJECTIVES: To evaluate
the effectiveness of non-surgical treatment (other than steroid
injection) for carpal tunnel syndrome versus a placebo or other
non-surgical, control interventions in improving clinical outcome.
SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease
Group specialised register (searched March 2002), MEDLINE (searched
January 1966 to February 7 2001), EMBASE (searched January 1980
to March 2002), CINAHL (searched January 1983 to December 2001),
AMED (searched 1984 to January 2002), Current Contents (January
1993 to March 2002), PEDro and reference lists of articles. SELECTION
CRITERIA: Randomised or quasi-randomised studies in any language
of participants with the diagnosis of carpal tunnel syndrome who
had not previously undergone surgical release. We considered all
non-surgical treatments apart from local steroid injection. The
primary outcome measure was improvement in clinical symptoms after
at least three months following the end of treatment. DATA COLLECTION
AND ANALYSIS: Three reviewers independently selected the trials
to be included. Two reviewers independently extracted data. Studies
were rated for their overall quality. Relative risks and weighted
mean differences with 95% confidence intervals were calculated
for the primary and secondary outcomes in each trial. Results
of clinically and statistically homogeneous trials were pooled
to provide estimates of the efficacy of non-surgical treatments.
MAIN RESULTS: Twenty-one trials involving 884 people were included.
A hand brace significantly improved symptoms after four weeks
(weighted mean difference (WMD) -1.07; 95% confidence interval
(CI) -1.29 to -0.85) and function (WMD -0.55; 95% CI -0.82 to
-0.28). In an analysis of pooled data from two trials (63 participants)
ultrasound treatment for two weeks was not significantly beneficial.
However one trial showed significant symptom improvement after
seven weeks of ultrasound (WMD -0.99; 95% CI -1.77 to - 0.21)
which was maintained at six months (WMD -1.86; 95% CI -2.67 to
-1.05). Four trials involving 193 people examined various oral
medications (steroids, diuretics, nonsteroidal anti-inflammatory
drugs) versus placebo. Compared to placebo, pooled data for two-week
oral steroid treatment demonstrated a significant improvement
in symptoms (WMD -7.23; 95% CI -10.31 to -4.14). One trial also
showed improvement after four weeks (WMD -10.8; 95% CI -15.26
to -6.34). Compared to placebo, diuretics or nonsteroidal anti-inflammatory
drugs did not demonstrate significant benefit. In two trials involving
50 people, vitamin B6 did not significantly improve overall symptoms.
In one trial involving 51 people yoga significantly reduced pain
after eight weeks (WMD -1.40; 95% CI -2.73 to -0.07) compared
with wrist splinting. In one trial involving 21 people carpal
bone mobilisation significantly improved symptoms after three
weeks (WMD -1.43; 95% CI -2.19 to -0.67) compared to no treatment.
In one trial involving 50 people with diabetes, steroid and insulin
injections significantly improved symptoms over eight weeks compared
with steroid and placebo injections. Two trials involving 105
people compared ergonomic keyboards versus control and demonstrated
equivocal results for pain and function. Trials of magnet therapy,
laser acupuncture, exercise or chiropractic care did not demonstrate
symptom benefit when compared to placebo or control. REVIEWER'S
CONCLUSIONS: Current evidence shows significant short-term benefit
from oral steroids, splinting, ultrasound, yoga and carpal bone
mobilisation. Other non-surgical treatments do not produce significant
benefit. More trials are needed to compare treatments and ascertain
the duration of benefit.
-----
Chir Main. 2003 Apr;22(2):65-72.
[Retinaculum flexors: clinical and experimental
anatomic bases in favor of reconstruction in
carpal tunnel surgery]
[Article in French]
Duche R, Trabelsi A, Dusserre F, Micallef JP.
Centre chirurgical de la main d'Avignon, clinique Fontvert-Avignon-Nord,
Val-du-Soleil, 84700 Sorgues, France. duche30@wanadoo.fr
The goal of this anatomical study is to prove that reconstruction
of the flexor retinaculum in carpal tunnel syndrome surgery is
a reliable procedure and can improve the results of this procedure.
In the first static study, we noted that when left to heal spontaneously,
after 3 months the gap between the two edges of the cut retinaculum
remained equal to or even larger than the gap created at the time
of the surgery. A special Canaletto implant was created to achieve
this reconstruction. It is technically possible to do this reconstruction
by a 2 to 3 cm surgical approach in the palm. In another, dynamic
study, we used a transducer to analyse the forces borne by the
retinaculum during flexor tendon contraction. We compared these
forces in a normal retinaculum, a reconstructed retinaculum with
the Canaletto implant and a retinaculum opened endoscopically.
This reconstruction conserves the anterior continuity of the retinaculum,
allows excellent carpal tunnel decompression and immediately permits
near-physiological forces. We discuss the advantages and the limits
of this reconstruction. We think that this new surgical technique
in the Carpal Tunnel Syndrome (CTS) will be able to improve the
results, particularly in recurrences, in wrist malunion with CTS,
in cases with severe electromyographic change with a sensory conduction
speed of under 15 m.s-1 and in metabolic CTS. As always, his implant
needs to be evaluated through a mid and long term clinical follow-up.
By recovering better grip strength and reducing postoperative
pain, this surgical technique can decrease the time needed to
return to work and hence the economic costs of CTS surgery.
-----
Plast Reconstr Surg. 2003 Apr 15;111(5):1616-22.
Open carpal tunnel release using a 1-centimeter
incision: technique and outcomes for 104 patients.
Klein RD, Kotsis SV, Chung KC.
Section of Plastic Surgery, Department of Surgery, University
of Michigan Health System, Ann Arbor 48109, USA.
The advantages of endoscopic carpal tunnel release, compared
with traditional open techniques, include smaller incisions, less
scar tenderness, and faster recoveries. However, endoscopic carpal
tunnel release has also been associated with higher complication
rates. The goal of this study was to evaluate the safety and functional
outcomes of minimal-incision open carpal tunnel release. In this
prospective study involving a 2-year period, 104 patients (149
hands) underwent open carpal tunnel release with a 1-cm incision.
Prospective data on complications among 104 patients were recorded,
and functional outcomes among 20 patients were assessed by using
the Michigan Hand Outcomes Questionnaire, the Jebsen-Taylor Hand
Function Test, and pinch/grip strength testing. Data were collected
before the operation and 3 weeks and 6 months after the operation.
Complications included three wound infections and one carpal tunnel
syndrome recurrence, 18 months after the initial release procedure.
Michigan Hand Outcomes Questionnaire scores improved significantly
between the preoperative and postoperative periods. There were
no significant changes in Jebsen-Taylor Hand Function Test results
or pinch/grip strength. Minimal-incision open carpal tunnel release
can be performed safely and is associated with good functional
outcomes.
-----
J Am Acad Nurse Pract. 2003 Jan;15(1):18-22.
Carpal tunnel syndrome: current theory, treatment,
and the use of B6.
Holm G, Moody LE.
University of South Florida, USA. dr.g.holm@usfaccess.com
PURPOSE: To present the current state of the science of pathophysiology,
assessment and treatment of carpal tunnel syndrome, including
the use of pyridoxine (B6). DATA SOURCES: Selected research articles,
texts, Websites, personal communications with experts, and the
authors' own clinical experience. CONCLUSIONS: Much is yet to
be learned about carpal tunnel syndrome. While the basic treatment
of NSAIDs and nighttime splints seems universally accepted, much
controversy remains. The use of vitamin B6 as a treatment is one
such controversy requiring further investigation. IMPLICATIONS
FOR PRACTICE: Current treatment for carpal tunnel syndrome should
include NSAIDs, nighttime splinting, ergonomic workstation review,
and vitamin B6 200 mg per day.
-----
Am Fam Physician. 2003 Feb 15;67(4):745-50.
Diagnostic and therapeutic injection of the wrist
and hand region.
Tallia AF, Cardone DA.
Department of Family Medicine, University of Medicine and Dentistry
of New Jersey-Robert Wood Johnson Medical School, New Brunswick,
New Jersey 08903, USA. tallia@umdnj.edu
Joint injection of the wrist and hand region is a useful diagnostic
and therapeutic tool for the family physician. In this article,
the injection procedures for carpal tunnel syndrome, de Quervain's
tenosynovitis, osteoarthritis of the first carpometacarpal joint,
wrist ganglion cysts, and digital flexor tenosynovitis (trigger
finger) are reviewed. Indications for carpal tunnel syndrome injection
include median nerve compression resulting from osteoarthritis,
rheumatoid arthritis, diabetes mellitus, hypothyroidism, repetitive
use injury, and other traumatic injuries to the area. For the
first carpometacarpal joint, injection may be used to treat pain
secondary to osteoarthritis and rheumatoid arthritis. Pain associated
with de Quervain's tenosynovitis is treated effectively by therapeutic
injection. If complicated by pain or paresthesias, wrist ganglion
cysts respond to aspiration and injection. Painful limitation
of motion occurring in trigger fingers of patients with diabetes
or rheumatoid arthritis also improves with injection. The proper
technique, choice and quantity of pharmaceuticals, and appropriate
follow-up are essential for effective outcomes.
-----
J Okla State Med Assoc. 2003 Mar;96(3):113-5.
Carpal tunnel syndrome in the elderly.
Nakasato YR.
VAMC (11G), P.O. Box 26901, Oklahoma City, OK 73190, USA.
Carpal Tunnel Syndrome (CTS) involves a compression of the
median nerve in the carpal tunnel. Incidence rates increase with
age for men, whereas for women the rates peak at 45-54 years.
Prevalence among older people is almost four times greater for
women than for men. Fifty percent of cases are idiopathic and
the rest associated with Colles' fracture, rheumatoid arthritis,
hormonal agents and/or oophorectomy, diabetes mellitus, and among
men, occupations with excessive use of hands. Age is a risk factor
for slowing of sensory conduction of the median nerve. Examination
includes provocative, sensibility and thenar muscle strength tests.
Electrophysiologic studies confirm diagnosis. No evidence that
NSAIDs, pyridoxine or diuretics work. Wrist splints, rest, local
injections and oral steroids work better. Surgery is successful
and even the very elderly show significant improvement. Although
the level of satisfaction is lower than in younger adults, surgery
is still worthwhile.
-----
J Hand Surg [Am]. 2003 Mar;28(2):255-61.
Predicting the outcome of carpal tunnel release.
Edgell SE, McCabe SJ, Breidenbach WC, LaJoie AS, Abell
TD.
Department of Psychological and Brain Sciences, University of
Louisville, Louisville, KY 40292, USA.
PURPOSE: To test the hypothesis that the result of steroid
injection in the carpal tunnel provides a better predictor of
the outcome of later surgery. We also explored other possible
factors that might predict the outcome directly or interact with
the results of steroid injection to better predict the outcome.
METHOD: We performed a historical cohort study on 57 patients
who had carpal tunnel release. Care was taken to avoid problems
of statistical nonindependence caused by both hands being studied
and confounding from previous surgeries. RESULTS: We found a large
and significant difference in the success rate of surgery for
patients who had obtained some relief from injection (87%) versus
those who had not (54%). No other significant predictor was found.
We discovered factors that may interact with the results of injection
in predicting the outcome of surgery (eg, Katz and Stirrat hand
diagram assessment of the probability of carpal tunnel syndrome)
although not significant in our study. CONCLUSIONS: Some relief
from steroid injection is the best predictor for success of surgery.
Further study is warranted to identify factors that interact with
this predictor.
-----
J R Soc Med. 2003 Feb;96(2):60-5.
Homeopathic arnica for prevention of pain and
bruising: randomized placebo-controlled trial in
hand surgery.
Stevinson C, Devaraj VS, Fountain-Barber A, Hawkins S,
Ernst E.
Department of Complementary Medicine, University of Exeter, UK.
Homeopathic arnica is widely believed to control bruising,
reduce swelling and promote recovery after local trauma; many
patients therefore take it perioperatively. To determine whether
this treatment has any effect, we conducted a double-blind, placebo-controlled,
randomized trial with three parallel arms. 64 adults undergoing
elective surgery for carpal tunnel syndrome were randomized to
take three tablets daily of homeopathic arnica 30C or 6C or placebo
for seven days before surgery and fourteen days after surgery.
Primary outcome measures were pain (short form McGill Pain Questionnaire)
and bruising (colour separation analysis) at four days after surgery.
Secondary outcome measures were swelling (wrist circumference)
and use of analgesic medication (patient diary). 62 patients could
be included in the intention-to-treat analysis. There were no
group differences on the primary outcome measures of pain (P=0.79)
and bruising (P=0.45) at day four. Swelling and use of analgesic
medication also did not differ between arnica and placebo groups.
Adverse events were reported by 2 patients in the arnica 6C group,
3 in the placebo group and 4 in the arnica 30C group. The results
of this trial do not suggest that homeopathic arnica has an advantage
over placebo in reducing postoperative pain, bruising and swelling
in patients undergoing elective hand surgery.
-----
J South Orthop Assoc. 2002 Fall;11(3):144-7.
Carpal tunnel release: efficacy and recurrence
rate after a limited incision release.
Ruch DS, Seal CN, Bliss MS, Smith BP.
Department of Orthopaedic Surgery, Wake Forest University School
of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1070,
USA. druch@wfubmc.edu
We retrospectively studied the postoperative outcomes of 51
patients treated for idiopathic carpal tunnel syndrome by method
of a limited incision carpal tunnel release. Patients were assessed
to determine: 1) palmar tenderness, 2) scar tenderness, 3) relief
of symptoms, 4) complications, and 5) recurrence. Short-term follow-up
included patient evaluations at 2 weeks, 4 weeks, and 10 weeks;
a mean of 2.5 years of follow-up also was obtained. Postoperatively,
nocturnal symptoms resolved by the 2-week visit. Palmar tenderness
was noted as minimal or absent between the 4-week and 10-week
visits in 47 of the 51 patients (92%). Symptom and function scores
improved from 4.24 and 4.00 preoperatively to 1.18 and 1.19 postoperatively.
At a mean of 2.5 years after surgery, none of the patients reported
recurrent symptoms.
-----
Cochrane Database Syst Rev. 2002;(4):CD003905.
Surgical treatment options for carpal tunnel syndrome.
Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet
HC, Bouter LM.
Dutch Cochrane Centre, PO 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. However,
there is no consensus on the most effective method of treatment.
OBJECTIVES: To compare the efficacy of the various surgical techniques
in relieving symptoms and promoting return to work and/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 conducted computer-aided searches of the Cochrane
Controlled Trials Register (Cochrane Library, Issue 1, 2000),
MEDLINE(searched January 1966-March 2000) and EMBASE (searched
January 1988-February 2000), and tracked references in bibliographies.
SELECTION CRITERIA: Randomised controlled trials comparing various
surgical techniques for the treatment of carpal tunnel syndrome.
DATA COLLECTION AND ANALYSIS: Study selection, assessment of methodological
quality and data abstraction were performed by two reviewers independently
of each other. MAIN RESULTS: Sixteen studies were included in
the review. The methodological quality of the trials was fair
to good. However, the application of allocation concealment was
mentioned explicitly in only two 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 seem
to offer better relief from symptoms in the short- or long-term.
There is conflicting evidence about whether endoscopic carpal
tunnel release results in earlier return to work and/or activities
of daily living than open carpal tunnel release. REVIEWER'S 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.
-----
Cochrane Database Syst Rev. 2002;(4):CD001554.
Local corticosteroid injection for carpal tunnel
syndrome.
Marshall S, Tardif G, Ashworth N.
Medicine, Division of Physical Medicine and Rehabilitation, University
of Ottawa, The Rehabilitation Centre, 505 Smyth Road, Ottawa,
Ontario, Canada, K1H 8M2. 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
level of the carpal tunnel in the wrist. Local corticosteroid
injection for carpal tunnel syndrome has been studied but its
effectiveness and duration of benefit of local corticosteroid
injection for Carpal tunnel syndrome remain unknown. OBJECTIVES:
To evaluate the effectiveness of local steroid injection for carpal
tunnel syndrome versus placebo injection or other non-surgical
interventions in improving clinical outcome and to determine the
length of symptom relief. SEARCH STRATEGY: We searched the Cochrane
Neuromuscular Disease Group register (searched June 2002), MEDLINE
(searched January 1966 to May 2002), EMBASE (searched January
1980 to May 2002)and CINAHL(searched January 1982 to May 2002).
SELECTION CRITERIA: We included randomized or quasi-randomized
studies of participants with carpal tunnel syndrome treated with
local corticosteroid injection. The primary outcome measure was
clinical improvement. DATA COLLECTION AND ANALYSIS: Three reviewers
independently selected the trials to be included rated for 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 identified nine
randomized controlled trials. Four were excluded. One trial demonstrated
clinical improvement of carpal tunnel syndrome at one month following
local corticosteroid compared to placebo injection (Relative risk
3.83 (95% confidence intervals 1.82 to 8.05)). One trial compared
local corticosteroid injection to oral steroid and at three months
after treatment there was a significant improvement in the injection
group (mean difference -7.00 (95% confidence intervals -11.58
to -2.42)). 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 for 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)). Although local steroid
injection did provide benefit compared to Helium-Neon Laser treatment
at two weeks after onset of treatment (Relative risk 0.27 (95%
CI 0.09 to 0.83), this effect did not hold at six months follow-up
(Relative risk 0.76 (95% confidence intervals 0.48 to 1.21). REVIEWER'S
CONCLUSIONS: Local corticosteroid injection for carpal tunnel
syndrome provides greater clinical improvement in symptoms one
month after injection compared to placebo. Symptom relief beyond
one month compared to placebo has not been demonstrated. Local
corticosteroid injection provides significantly greater clinical
improvement compared to oral steroid up to three months after
treatment. Local corticosteroid injection does not provide improved
clinical outcome compared to either anti-inflammatory treatment
and splinting after eight weeks or Helium -Neon laser treatment
after six months.
-----
Acta Orthop Traumatol Turc. 2002;36(3):259-64.
[The results of open surgical release in carpal
tunnel syndrome and evaluation of follow-up criteria]
[Article in Turkish]
Akman S, Erturer E, Celik M, Aksoy B, Gur B, Ozturk I.
Department of Orthopedics and Traumatology (2. Ortopedi ve Travmatoloji
Klinigi), Sisli Etfal Training and Research Hospital, Istanbul,
Turkey. senolakman@hotmail.com
OBJECTIVES: We evaluated the results of open surgical release
in patients with carpal tunnel syndrome (CTS) and assessed the
necessity of a clinical scoring system and electromyography (EMG)
in the postoperative follow-up. METHODS: The study included 24
wrists of 15 patients (9 females, 6 males; mean age 49.2 years;
range 23 to 70 years) in whom a diagnosis of CTS was made by clinical
examination and EMG. The patients underwent open surgical release
and were followed-up for a mean of 21.5 months (range 7 to 40
months), during which they were evaluated by the Boston scale
(BS) for clinical scoring and EMG. Postoperative findings of BS
and EMG were compared in terms of their utility during follow-up.
RESULTS: Statistically significant differences were found between
preoperative and follow-up EMG values of motor distal latency,
sensorial latency, combined motor muscle potential amplitudes,
and sensorial latency amplitudes (p<0.05). Of twenty-four wrists,
16 (66.6%) showed improvement, and eight (33.3%) showed marked
improvement. Similarly, preoperative and follow-up BS scores showed
significant differences in favor of treatment results (p<0.05).
The Boston scale scores and EMG results were found consistent
in showing treatment outcome. CONCLUSION: Open surgical release
of CTS provides favorable results that can be sufficiently evaluated
by the clinical scoring system alone. Electromyographic studies
do not seem to add extra benefits to the postoperative evaluation
of patients with CTS.
-----
Acta Orthop Traumatol Turc. 2002;36(4):346-53.
[Analysis of the causes of failure in carpal tunnel
syndrome surgery and the results of reoperation]
[Article in Turkish]
Bagatur AE.
Department of Orthopedics and Traumatology (1. Ortopedi ve Travmatoloji
Klinigi), SSK Istanbul Training Hospital, 34098 Kocamustafapasa,
Fatih, Turkey. bagatur@ixir.com
OBJECTIVES: We investigated the causes of failure and ensuing
problems and findings in patients with unrelieved or recurrent
carpal tunnel syndrome (CTS) and evaluated the results of revision
surgery. METHODS: The study included 26 patients (21 women, 5
men; mean age 52 years; range 30 to 71 years) who underwent reoperation
for unrelieved or recurrent symptoms following at least a year
(range 1 to 4 years) after the initial surgery. A total of 34
operations had been carried out in 31 hands. All patients were
investigated clinically and electrophysiologically. The mean follow-up
after reoperation was 19 months (range 12 to 38 months). RESULTS:
The diagnosis was confirmed in all patients by clinical and electrophysiologic
studies. The primary operations had been performed using 11 transverse
incisions, three incisions confined proximally to the wrist crease,
10 incisions without insufficient distal extension, and seven
appropriate incisions. The transverse carpal ligament release
was inadequate in 23 hands; it had not been released in three
hands at all. Excessive fibrous tissue developed in one patient,
leading to complete bilateral median nerve compression. Bilateral
and unilateral tenosynovitis resulting from rheumatoid arthritis
and tuberculosis was detected in two patients, respectively. All
patients underwent repeat open carpal tunnel release. Neurolysis
and tenosynovectomy were performed in both hands of one patient
and in one hand of two patients, respectively. Clinical results
were excellent in 24 hands, good in six hands, and fair in one
hand. CONCLUSION: Selection of appropriate incision and achievement
of complete carpal tunnel release without any injury to the median
nerve or its branches are of great importance with regard to postoperative
results. Careful imaging studies of the carpal tunnel should be
carried out especially in patients with unilateral involvement,
presenting with an atypical age or occupation.
-----
Minim Invasive Neurosurg. 2002 Dec;45(4):228-30.
Comparing open surgery with endoscopic releasing
in the treatment of carpal tunnel syndrome.
Kiymaz N, Cirak B, Tuncay I, Demir O.
Department of Neurosurgery, Yuzuncu Yil University School of Medicine,
Van, Turkey. nkiymaz@hotmail.com
AIM: The aim of this study is to retrospectively assess the
complications and result of cases that underwent open surgery
or endoscopic releasing for carpel tunnel syndrome. METHOD: A
total of 50 cases of carpel tunnel syndrome, 30 of whom underwent
endoscopic release using the biportal extrabursal technique described
by Chow, and the other 20 that underwent open surgery were included
in the study. Average age of the cases was 41 (24 - 62), 44 of
them were females and 6 males. RESULTS: Follow-up examinations
of the patients at the first and third month after operation revealed
no limitation of activity in 40 (80 %) cases, minimal limitation
in 4 (8 %), moderate limitation in 5 (10 %) and significant limitation
in 1 (2 %). Among the group that underwent endoscopic release,
as a major complication, the median nerve was almost totally cut
in a patient undergoing endoscopic release. During the same operation
setting perifascicular neurorrhaphy was done. Fourth and fifth
digital nerve lesions occurred in three cases. Among the group
that underwent open surgery fourth and fifth digital nerve injury
occurred in one case, and in another case severe inflammation
requiring reoperation occurred. CONCLUSION: Before intervention,
cases of carpal tunnel syndrome should be examined well as regards
which technique to use. Experience of the surgeon with the technique
to be used should also be taken into consideration. Endoscopic
carpal tunnel releasing, though a relatively easier procedure,
leads to neurovascular injuries more frequently than open surgery;
thus open surgery appears to be safer.
-----
J Hand Surg [Am]. 2002 Nov;27(6):1019-25.
Canal pressures before, during, and after endoscopic
release for idiopathic carpal tunnel syndrome.
Schuind F.
Service d'Orthopedie-Traumatologie, Cliniques Universitaires de
Bruxelles, Hopital Erasme, Brussels, Belgium.
A special transducer was used to measure in situ carpal tunnel
pressures in 20 patients who had surgery for idiopathic carpal
tunnel syndrome (CTS) by one-portal endoscopic section of the
flexor retinaculum. Pressures were elevated initially. The pressures
were maximal (mean, 93 mm Hg) with full passive wrist extension.
Peaks of high pressures, on average 97 mm Hg, were recorded with
the Agee (MicroAire, Charlottesville, VA) endoscopic device in
the canal. Release of the endoscopic flexor retinaculum resulted
in a marked decrease of the pressures.
-----
J Hand Surg [Am]. 2002 Nov;27(6):1011-8.
Endoscopic carpal tunnel release: thirteen years'
experience with the Chow technique.
Chow JC, Hantes ME.
Orthopaedic Center of Southern Illinois, Mt. Vernon, IL 62864,
USA.
The purpose of this single-center study was to evaluate the
results of endoscopic carpal tunnel release (ECTR) by using the
dual portal Chow technique in a large series of patients. A total
of 2,675 procedures in 1,886 patients were performed during a
13-year period. Follow-up evaluation was performed in 2,402 (90%)
cases or 1,698 (90%) patients. The success rate was 95% and the
recurrence rate was 0.5%. A total of 106 cases (4.5%) were considered
failures or had unsatisfactory results. The overall complication
rate was 1.1% but no serious complications occurred in this series.
The return-to-work status was followed-up in 1,156 patients; 90%
of non-worker's compensation patients and 60% of worker's compensation
patients returned to work within 4 weeks. This study suggests
that ECTR for carpal tunnel syndrome (CTR) is a reliable procedure
with a high success rate. Based on our 13 years of experience,
we believe that the technique is safe and iatrogenic complications
can be avoided with meticulous surgical technique.
-----
J Neurol Neurosurg Psychiatry. 2002 Dec;73(6):710-4.
A randomised clinical trial of oral steroids in
the treatment of carpal tunnel syndrome:
a long term follow up.
Chang MH, Ger LP, Hsieh PF, Huang SY.
Section of Neurology, Taichung Veterans General Hospital and Department
of Neurology, National Yang-Ming University, Taipei, Taiwan. cmh50@ms10.hinet.net
OBJECTIVES: To determine the efficacy of a two week and a four
week course of oral steroids in the conservative treatment of
carpal tunnel syndrome. METHODS: 109 patients with carpal tunnel
syndrome were randomly divided into two treatment groups: (1)
two weeks of prednisolone 20 mg daily followed by two weeks of
prednisolone 10 mg daily (n = 53); (2) two weeks of prednisolone
20 mg daily and two weeks of placebo (n = 56). A symptom questionnaire
was used to rate the five major symptoms of carpal tunnel syndrome
(numbness, pain, weakness/clumsiness, tingling, and nocturnal
awakening) on a scale of 0 (nil) to 10 (severe); the resulting
global symptom score was used to evaluate the efficacy of treatment.
Assessments were made at baseline and at one, three, six, nine,
and 12 months. Electrodiagnosis was repeated at the end of the
study to validate improvement. RESULTS: In an intention to treat
analysis at the end of the study, improvement in the four week
treatment group was achieved in 66.0% of the patients after one
month and in 49.0% at the end of the study; in the two week treatment
group, the respective values were 48.2% and 35.7%. In the four
week treatment group, 51% were considered treatment failures (including
those lost to follow up, receiving surgery, or with mild or no
improvement), compared with 64.3% for the two week group. Though
the percentage improvement was higher in the four week group,
the difference did not reach a statistical significance. Persistence
of improvement was 74.2% in the four week group v 74.1% in the
two week group, suggesting no difference in the long term effect.
Efficacy analysis showed no significant difference in global symptom
score reduction between the two groups. Follow up electrodiagnosis
showed significant improvement in all measured variables except
for the amplitude of compound muscle action potentials. CONCLUSIONS:
Short term low dose oral steroid are effective treatment for carpal
tunnel syndrome. The dose of steroids and the duration treatment
are not key determinants of efficacy.
-----
Am J Orthop. 2002 Oct;31(10):571-4.
Grip strength after carpal tunnel release: role
of the transverse caxpal ligament.
Kozin SH, Pagnanelli DM.
Department of Orthopaedic Surgery, Temple University, Philadelphia,
Pennsylvania, USA.
Weakness after carpal tunnel release is common. Potential factors
are transverse carpal ligament (TCL) division, incision or pillar
pain, swelling, and flexor tenosynovitis. In the study reported
here, we examined the effect of TCL division on reactive grip-strength
changes. A minimally invasive technique was used with local anesthesia
and sedation for TCL release in 41 hands. Total grip strength
and individual-digit grip strength were measured using a computerized
dynamometer. These measurements were taken preoperatively; immediately
after TCL division; and 1, 3, and 5 weeks postoperatively. There
was no significant difference between total grip strength measured
preoperatively and strength measured immediately after TCL division,
but the difference between these values and strength measured
1 week postoperatively was significant. Preoperatively, index
fingers contributed 25.3% of total grip strength; long fingers,
31.3%; ring fingers, 27.0%; and small fingers, 16.4%. These contributions
were approximately the same after TCL division
-----
Wien Med Wochenschr. 2002;152(17-18):479-80.
[Postoperative rehabilitation of patients with
carpal tunnel syndrome]
[Article in German]
Keilani MY, Crevenna R, Fialka-Moser V.
Universitatsklinik fur Physikalische Medizin und Rehabilitation,
Wahringer Gurtel 18-20, A-1090 Wien. mohammad.keilani@univie.ac.at
The purpose of this study was to investigate the effect of
mobilisation or splinting on symptoms after surgical Treatment
of Carpal Tunnel Syndrome. Only original articles concerning the
effect of mobilisation or splinting on symptoms after surgical
Treatment of Carpal Tunnel Syndrome were included in this investigation.
Concerning these topics only seven original articles were found.
There was no significant influence of splinting for several weeks
found on the symptom "pain" in the literature. Even
there was a delay of returning to activities of daily living and
the recovery of fist und keypinch strength through splinting.
A program of physiotherapy and ergotherapy lead to a significant
shorter recovery of dexterity in comparison to an home exercise
program. Even the rehabilitated patients showed a shorter return-to-work
interval. After carpal tunnel surgery neither physiotherapy nor
splinting lead to a significant release of the symptom "pain".
But physiotherapy leads to a shorter recovery of dexterity and
shorter return-to-work interval. Due to the lack of knowledge
about this topic further controlled clinical studies investigating
the rehabilitation process after carpal tunnel surgery would be
necessary.
-----
Hand Clin. 2002 May;18(2):339-45.
Recurrent carpal tunnel syndrome.
Steyers CM.
Department of Orthopaedic Surgery, University of Iowa Hospitals
and Clinics, 200 Newton Road, Iowa City, IA 52242-1008, USA. curtis-steyers@uiowa.edu
Persistent or recurrent symptoms following carpal tunnel release
surgery are an infrequent but challenging clinical problem. A
thorough evaluation of these patients is mandatory and must confirm
the accuracy of the original diagnosis and rule out the presence
of concurrent conditions or disorders that may cause persistent
symptoms that mimic carpal tunnel syndrome. If an alternative
explanation of the patients' symptoms cannot be identified, and
if conservative care is ineffective, then surgical treatment should
be considered. Adequate exposure of the median nerve and carpal
tunnel are mandatory. The general approach should include gentle
mobilization of the nerve from adherent scar tissue and interposition
of a biologic barrier between the nerve and surrounding tissues.
No published data conclusively demonstrate that internal neurolysis
provides superior results. Postoperative care should include early
mobilization to encourage tendon and nerve gliding.
-----
Hand Clin. 2002 May;18(2):315-23.
Role of ancillary procedures in surgical management
of carpal tunnel syndrome: epineurotomy, internal neurolysis,
tenosynovectomy, and tendon transfers.
Ting J, Weiland AJ.
Division of Plastic and Reconstructive Surgery, Mount Sinai School
of Medicine, Mount Sinai Hospital, One Gustave Levy Place, P.O.
Box 1263, New York, NY 10029, USA. ting_jess@yahoo.com
The role of ancillary procedures in the treatment of carpal
tunnel syndrome is controversial, especially with regard to internal
neurolysis and epineurotomy. At present, there are little to no
data to support their routine use in the treatment of primary
carpal tunnel syndrome. Similarly, the use of tenosynovectomy
in carpal tunnel surgery should be limited to those patients with
clear underlying rheumatologic or inflammatory risk factors, or
with gross synovitis incidentally noted at surgery. The Camitz
transfer is uniquely suited to treating the thenar wasting seen
in advanced carpal tunnel syndrome. It can be performed concurrently
with open carpal tunnel release with minimal additional dissection
and morbidity.
-----
Hand Clin. 2002 May;18(2):307-13.
Endoscopic carpal tunnel release.
Nagle DJ.
Department of Orthopaedics, Northwestern University Medical School,
448 East Ontario Street, Suite 500, Chicago, IL 60611, USA.
Endoscopic carpal tunnel release is not a procedure to be taken
lightly. Like many surgical procedures, it is a demanding exercise
that requires exacting knowledge of the anatomy of the hand, attention
to detail, and the ability to manipulate three-dimensional objects
while observing them in two dimensions on a video screen. In the
hands of well trained surgeons, ECTR provides patients with a
safe, predictable solution to their carpal tunnel sydrome that
will allow them a rapid return to normal activities with minimal
postoperative discomfort.
-----
Hand Clin. 2002 May;18(2):299-306.
Carpal tunnel release via limited palmar incision.
Higgins JP, Graham TJ.
Curtis National Hand Center, Union Memorial Hospital, Johnston
Professional Building, Mezzanine, 3333 North Calvert Street, Baltimore,
MD 21218, USA.
The limited incision carpal tunnel release provides an effective,
reliable, and safe method for decompression of the median nerve
at the wrist. The technique described above minimizes risk of
complication through the design of the instruments and conceptual
approach to the anatomy and surgical exposure. This method combines
the reduced postoperative pain and quicker recovery of the ECTR
technique with the safety and lower operative expense of the conventional
open technique.
-----
Hand Clin. 2002 May;18(2):291-8.
Surgical release of the carpal tunnel.
Steinberg DR.
Penn Orthopaedic Institute, University of Pennsylvania School
of Medicine, 1 Cupp Pavilion, 39th & Market Street, Philadelphia,
PA 19104, USA. david.steinberg@uphs.upenn.edu
A thorough understanding of the normal anatomy and possible
anomalies that may exist is important for the surgeon managing
median nerve compression at the wrist. Given the high incidence
of anatomic variability occurring in and around the carpal canal,
open decompression of the median nerve is the preferred surgical
technique for treating carpal tunnel syndrome. This approach provides
complete visualization of the region, enabling the surgeon to
decompress the nerve thoroughly, identify and treat anatomic abnormalities,
and protect important neurovascular structures. Open carpal tunnel
release is a safe and reliable operation with a high rate of functional
improvement and patient satisfaction.
-----
Swiss Surg. 2002;8(4):181-5.
[Experiences with endoscopic carpal tunnel release]
[Article in German]
Buchli Ch, Scharplatz D.
Chirurgische Abteilung, Krankenhaus Thusis.
Between 1994 and 2000 122 open and endoscopic carpal tunnel
releases were performed. 82 of them were analysed retrospectively
with major interest in security and results of the endoscopic
technique. 39 patients were treated with an open, 41 patients
with an endoscopic carpal tunnel release (26 using the two portal
technique, 17 using the single portal technique). No major irreversible
complications were reported, regarding the outcome their were
no significant differences. From the 39 patients with open carpal
tunnel release nine had persistent complaints and one of them
was reoperated because of an injury of the motoric branch of the
median nerve. Eight patients out of 26 treated with the two portal
technique still had complaints and one needed to be reoperated
because of excessive fibrosis around the median nerve. From the
17 patients operated with the single portal technique five had
persistent complaints but no reoperation was necessary. Our study
showed similar findings regarding security and results using the
three different operation methods. But there were no advantages
for the endoscopic carpal tunnel release because of the more atraumatic
procedure.
-----
JAMA. 2002 Sep 11;288(10):1245-51.
Splinting vs surgery in the treatment of carpal
tunnel syndrome: a randomized controlled trial.
Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de
Krom MC, Bouter LM.
Institute for Research in Extramural Medicine, Vrije Universiteit
Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam,
The Netherlands. aam.gerritsen.emgo@med.vu.nl
CONTEXT: Carpal tunnel syndrome (CTS) can be treated with nonsurgical
or surgical options. However, there is no consensus on the most
effective method of treatment. OBJECTIVE: To compare the short-term
and long-term efficacy of splinting and surgery for relieving
the symptoms of CTS. DESIGN, SETTING, AND PATIENTS: A randomized
controlled trial conducted from October 1998 to April 2000 at
13 neurological outpatient clinics in the Netherlands. A total
of 176 patients with clinically and electrophysiologically confirmed
idiopathic CTS were assigned to wrist splinting during the night
for at least 6 weeks (89 patients) or open carpal tunnel release
(87 patients); 147 patients (84%) completed the final follow-up
assessment 18 months after randomization. MAIN OUTCOME MEASURES:
General improvement, number of nights waking up due to symptoms,
and severity of symptoms. RESULTS: In the intention-to-treat analyses,
surgery was more effective than splinting on all outcome measures.
The success rates (based on general improvement) after 3 months
were 80% for the surgery group (62/78 patients) vs 54% for the
splinting group (46/86 patients), which is a difference of 26%
(95% confidence interval [CI], 12%-40%; P<.001). After 18 months,
the success rates increased to 90% for the surgery group (61/68
patients) vs 75% for the splinting group (59/79 patients), which
is a difference of 15% (95% CI, 3%-27%; P =.02). However, by that
time 41% of patients (32/79) in the splint group had also received
the surgery treatment. CONCLUSION: Treatment with open carpal
tunnel release surgery resulted in better outcomes than treatment
with wrist splinting for patients with CTS.
-----
J Hand Ther. 2002 Jul-Sep;15(3):226-33.
Comparison of range-of-motion constraints provided
by prefabricated splints used in the treatment of carpal tunnel
syndrome: a pilot study.
Apfel E, Johnson M, Abrams R.
Department of Physical Medicine and Rehabilitation Medicine, Veterans
Administration Healthcare System, San Diego, California 92161,
USA. apfelroberts@worldnet.att.net
Nocturnal splinting of the wrist is commonly used to treat
carpal tunnel syndrome. Rationales for overnight wrist splinting
are based on several research studies, which suggest that passively
and actively sustained positions of the wrist and digits during
sleep contribute to elevated carpal tunnel pressures. The types
of splints used for carpal tunnel syndrome include custom and
prefabricated orthoses of many variations. The purpose of this
paper is to assess the resting and passive range-of-motion position
restrictions and parameters provided by four prefabricated orthoses
commonly prescribed for or used by patients at the authors' treatment
facility. A literature review provides information that supports
optimal wrist and finger positioning to minimize resting carpal
tunnel pressures. This information may be useful in determining
the most effective splint design choices.
-----
Rozhl Chir. 2002 Jul;81(7):372-5.
[Problems due to workload after surgical treatment
of carpal tunnel syndrome]
[Article in Czech]
Zinek K, Ehler E, Zakova A, Broz T.
Neurochirurgicke oddeleni, Nemocnice Pardubice.
The authors present a group of patients operated on account
of the carpal tunnel syndrome in 1998-2000 at the Neurosurgical
department in Pardubice. The group comprised 37 patients. 15 men
and 22 women. The main objective of the retrospective investigation
was to assess the period of work incapacity and asset of the operation
from the aspect to proceed with the usual workload. The authors
also tried to evaluate the effect of age, sex, occupation, preoperative
clinical and electromyographic finding on the resulting effect
of the operation. The period of work incapacity after one operation
was 114 days. 84% patients returned to their original job. In
11% it was necessary to enlist in different work and a disability
pension was granted to 5% patients. The discussion is focused
on the period of work incapacity, enlistment in work, the effect
of operation on the patients complaints and the objective finding
as regards the lesion of fibres of the median nerve and also on
the asset of EMG in the diagnosis and postoperative follow up.
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Neurosurg Rev. 2002 Aug;25(4):218-21. Epub 2002 Apr 05.
Clinical outcome and predictive value of electrodiagnostics
in endoscopic carpal tunnel surgery.
Vogt T, Scholz J.
Department of Neurology, University Hospital Mainz, Langenbeckstrasse
1, Germany. vogt@neurologie.klinik.uni-mainz.de
Forty-three patients (50 hands) with clinically and electrophysiologically
confirmed carpal tunnel syndrome were included in a prospective
study to determinate the clinical outcome and electrophysiological
recovery of the median nerve after endoscopic transection of the
transverse carpal ligament (TCL). Evaluation included a questionnaire
for symptoms, physical examination, grip force measurements, and
electrophysiological testing before surgery and at weeks 4 and
20 after surgery. As compared to the preop baseline, the rates
of permanent paraesthesia, pain, the presence of Tinel's sign,
and thenar atrophy decreased significantly. The majority (94%)
of the patients had no residual disturbances and were satisfied
with the results. Complications were observed in 4.5%, and the
treatment had to be changed to an open release. Nerve conduction
studies (NCS) showed significant improvement, but many were still
abnormal after 4 months. Since failure of improvement could not
be predicted by the electrophysiological data, monitoring the
postoperative nerve conduction is not very sensitive in characterising
the individual clinical course. Our patients were in hospital
for 3.3 days. The time of return to work differed between patients
that were self employed (4.3 days) and those working as employees
(19 days).
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Scand J Plast Reconstr Surg Hand Surg. 2002;36(3):172-6.
Coverage of the median nerve with free and pedicled
flaps for the treatment of recurrent severe carpal tunnel syndrome.
Dahlin LB, Lekholm C, Kardum P, Holmberg J.
Department of Hand Surgery, University Hospital Malmo, SE 205
02 Malmo, Sweden. Lars.Dahlin@hand.mas.lu.se
Fifteen patients (10 women and 5 men; median age 46 years;
range 28-55), with recurrent severe carpal tunnel syndrome, were
operated on with re-exploration and cover of the median nerve
with free or pedicled flaps (five pedicled ulnar flaps, one pedicled
dorsal forearm flap (served by the posterior interosseus artery),
one groin flap, three free scapular flaps, and five free lateral
arm flaps). The patients were followed up by a self-administered
questionnaire at 3 months-14 years (median 8.5 years) after operation
and replies were obtained from 14 patients. There was a significant
improvement in pain (p = 0.01) and percussion tenderness at the
wrist (p = 0.02), but no significant improvement in allodynia
and cold intolerance in the hand as evaluated by the use of a
visual analogue scale (VAS). Three of the 14 patients had less
numbness/paraesthesiae and four had subjectively improved sensory
function in the hand and fingers since the procedure. Ten patients
had problems from the donor site, including a cosmetically unacceptable
scar, allodynia, and itching. Four patients had worked before
the operation and nine patients returned to ordinary or light
work afterwards. In conclusion, 10/14 patients considered themselves
as somewhat better, better, or cured, while four felt that they
were unchanged or worse. We conclude that cover with vascularised
fat may be worthwhile in some patients with recurrent severe carpal
tunnel syndrome, preferably with a simple pedicled ulnar flap.
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