Summary Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome worldwide. The clinical symptoms and physical examination findings in patients with this syndrome are recognised ...widely and various treatments exist, including non-surgical and surgical options. Despite these advantages, there is a paucity of evidence about the best approaches for assessment of carpal tunnel syndrome and to guide treatment decisions. More objective methods for assessment, including electrodiagnostic testing and nerve imaging, provide additional information about the extent of axonal involvement and structural change, but their exact benefit to patients is unknown. Although the best means of integrating clinical, functional, and anatomical information for selecting treatment choices has not yet been identified, patients can be diagnosed quickly and respond well to treatment. The high prevalence of carpal tunnel syndrome, its effects on quality of life, and the cost that disease burden generates to health systems make it important to identify the research priorities that will be resolved in clinical trials.
Aims
We aimed to assess carpal tunnel syndrome (CTS) prevalence in transthyretin (TTR)‐related and light‐chain amyloidosis (AL), comparing it to the general population, adjusted for age and gender. ...In TTR‐related amyloidosis (ATTR) we investigated (i) CTS prevalence in relation to genotype, cardiac amyloidosis (CA), age and gender; (ii) CTS role as an incremental risk factor for CA; (iii) temporal relationship between CTS and CA; and (iv) CTS prognostic role.
Methods and results
Data from 538 subjects (166 hereditary ATTR, 107 wild‐type ATTR, 196 AL amyloidosis, and 69 TTR mutation carriers; 64% male, median age 62.4 years), evaluated at our centre (Bologna, Italy), were analysed and compared to a published cohort of 14.9 million people, in which incidence rates of CTS had been estimated. CTS prevalence was highest in ATTR patients with CA (20.3% vs. 4.1% in the general population), while it was comparable to the general population when CA was absent and in AL patients. CTS standardized incidence rates were markedly elevated in ATTR males in the eighth decade of life (13.08 in hereditary ATTR, 15.5 in wild‐type ATTR). The risk of developing CA was greater in ATTR patients with CTS; the probability of having CTS was highest 5–9 years prior to CA diagnosis. CTS was an independent mortality risk factor in ATTR.
Conclusions
Compared to general population the adjusted prevalence of CTS is higher among elderly men with ATTR; CTS is a prognostic marker in ATTR, independently of cardiac involvement, and precedes CA diagnosis by 5–9 years. The awareness of this association and time delay offers the possibility of an early pre‐clinical ATTR‐CA diagnosis.
Carpal tunnel syndrome Middleton, Scott D; Anakwe, Raymond E
BMJ (Online),
11/2014, Letnik:
349, Številka:
nov06 1
Journal Article, Book Review
Recenzirano
Carpal tunnel syndrome is the most commonly diagnosed compression neuropathy of the upper limb. Patients may present to general practitioners, physiotherapists, hand therapists, or surgeons with a ...variety of symptoms. Several studies have examined the epidemiology, diagnosis, and treatment of carpal tunnel syndrome. We review these resources to provide an evidence based guide to the diagnosis and treatment of carpal tunnel syndrome.
Carpal Tunnel Syndrome LeBlanc, Kim Edward, MD, PhD; Cestia, Wayne, MD
American family physician,
04/2011, Letnik:
83, Številka:
8
Journal Article
Recenzirano
Carpal tunnel syndrome is the most common entrapment neuropathy, affecting approximately 3 to 6 percent of adults in the general population. Although the cause is not usually determined, it can ...include trauma, repetitive maneuvers, certain diseases, and pregnancy. Symptoms are related to compression of the median nerve, which results in pain, numbness, and tingling. Physical examination findings, such as hypalgesia, square wrist sign, and a classic or probable pattern on hand symptom diagram, are useful in making the diagnosis. Nerve conduction studies and electromyography can resolve diagnostic uncertainty and can be used to quantify and stratify disease severity. Treatment options are based on disease severity. Six weeks to three months of conservative treatment can be considered in patients with mild disease. Lifestyle modifications, including decreasing repetitive activity and using ergonomic devices, have been traditionally advocated, but have inconsistent evidence to support their effectiveness. Cock-up and neutral wrist splints and oral corticosteroids are considered first-line therapies, with local corticosteroid injections used for refractory symptoms. Nonsteroidal anti-inflammatory drugs, diuretics, and pyridoxine (vitamin B6 ) have been shown to be no more effective than placebo. Most conservative treatments provide short-term symptom relief, with little evidence supporting long-term benefits. Patients with moderate to severe disease should be considered for surgical evaluation. Open and endoscopic surgical approaches have similar five-year outcomes.
Aims
To assess whether diabetes increases the risk of carpal tunnel syndrome and to estimate the magnitude of the association with Type 1 and Type 2 diabetes.
Methods
We conducted a systematic search ...of PubMed, Embase, Web of Science, Scopus, Google Scholar and ResearchGate for articles published between 1950 and January 2015. A total of 36 studies (eight cross‐sectional, 21 case–control and seven cohort studies) qualified for meta‐analysis. We used a random‐effects meta‐analysis and assessed heterogeneity and publication bias.
Results
The pooled odds ratio of 25 studies (including a total of 92 564 individuals) that reported unadjusted estimates for the association between diabetes and carpal tunnel syndrome or carpal tunnel release was 1.97 (95% CI 1.56–2.49). The pooled odds ratio of 18 case–control or cohort studies consisting of >37 million individuals that reported estimates after controlling for potential confounders was 1.69 (95% CI 1.45–1.96). The association did not differ for Type 1 and Type 2 diabetes. Furthermore, there was no publication bias.
Conclusion
This meta‐analysis suggests that both Type 1 and Type 2 diabetes are risk factors for carpal tunnel syndrome.
OBJECTIVEThe aim of the study was to investigate the overall estimates of cross-sectional areas of the median nerve measured by ultrasonography in accordance with the electrodiagnostic classification ...of carpal tunnel syndrome severity.
DESIGNMEDLINE (PubMed), Embase (Ovid), and Web of Science were searched for studies reporting the median nerve cross-sectional area measured by ultrasonography for mild, moderate, and severe carpal tunnel syndrome based on electrodiagnostic study. Cross-sectional area values measured at the carpal tunnel inlet were included in the analyses.
RESULTSOverall, 866 citations were retrieved and checked for eligibility. Finally, 16 articles were included for meta-analysis. These studies included a total sample of 2292 wrists including 776 mild, 823 moderate, and 693 severe carpal tunnel syndrome. The pooled analysis revealed a mean cross-sectional area of 11.64 mm (95% confidence interval = 11.23–12.05 mm, P < 0.001) for mild carpal tunnel syndrome, a mean cross-sectional area of 13.74 mm (95% confidence interval = 12.59–14.89 mm, P < 0.001) for moderate carpal tunnel syndrome, and a mean cross-sectional area of 16.80 mm (95% confidence interval = 14.50–19.1 mm, P < 0.001) for severe carpal tunnel syndrome.
CONCLUSIONSThis is the first meta-analysis that provides the pooled median nerve cross-sectional area values in accordance with the electrodiagnostic classification of carpal tunnel syndrome severity. The values obtained in this study have clinical utility in ultrasonographic assessment of patients with carpal tunnel syndrome.
•Based on expert consensus combining electrodiagnosis and ultrasound is more informative than either modality alone.•When electrodiagnostic studies are normal or fail to localize suspected carpal ...tunnel syndrome, ultrasound adds value.•Electrodiagnostic studies add value to ultrasound in quantifying severity of carpal tunnel syndrome and in testing individuals over age 70.
Expert consensus was sought to guide clinicians on the use of electrodiagnostic tests (EDX) and neuromuscular ultrasound (NMUS) in the investigation of suspected carpal tunnel syndrome (CTS).
Consensus was achieved using the Delphi method via three consecutive anonymised surveys of 15 experts and was defined as rating agreement ≥ 80%.
The panel agreed that combining EDX and NMUS is more informative than using each modality alone. NMUS adds value in patients with clinically suspected CTS with non-localizing or normal EDX, atypical EDX, failed CTS surgery, polyneuropathy, and CTS suspected to be secondary to structural pathology. The median nerve cross-sectional area should be measured at the site of maximal nerve enlargement, and the nerve should be scanned from mid-forearm to the palm. The group also identified those situations where the wrist-to-forearm area ratio and longitudinal scans of the median nerve should also be obtained. EDX should always be performed to quantify CTS severity and in individuals over age 70.
This document is an initial step to guide clinicians on the combined investigation of CTS using EDX and NMUS, to be updated regularly with the emergence of new research.
We aimed to estimate the effects of overweight and obesity on carpal tunnel syndrome (CTS), and to assess whether sex modifies the associations. Literature searches were conducted in PubMed, Embase, ...Web of Science, Scopus, Google Scholar and ResearchGate databases from 1953 to February 2015. Fifty‐eight studies consisting of 1,379,372 individuals qualified for a meta‐analysis. We used a random‐effects meta‐analysis, assessed heterogeneity and publication bias, and performed sensitivity analyses. Overweight increased the risk of CTS or carpal tunnel release 1.5‐fold (pooled confounder‐adjusted odds ratio OR = 1.47, 95% CI 1.37–1.57, N = 1,279,546) and obesity twofold (adjusted OR = 2.02, 95% CI 1.92–2.13, N = 1,362,207). Each one‐unit increase in body mass index increased the risk of CTS by 7.4% (adjusted OR = 1.074, 95% CI 1.071–1.077, N = 1,258,578). Overweight and obesity had stronger effects on carpal tunnel release than CTS. The associations did not differ between men and women, and they were independent of study design. Moreover, the associations were not due to bias or confounding. Excess body mass markedly increases the risk of CTS. As the prevalence of overweight and obesity is increasing globally, overweight‐related CTS is expected to increase. Future studies should investigate whether a square‐shaped wrist and exposure to physical workload factors potentiate the adverse effect of obesity on the median nerve.
Carpal tunnel syndrome is the most common entrapment neuropathy, affecting the median nerve at the wrist. Acupuncture is a minimally-invasive and conservative therapeutic option, and while rooted in ...a complex practice ritual, acupuncture overlaps significantly with many conventional peripherally-focused neuromodulatory therapies. However, the neurophysiological mechanisms by which acupuncture impacts accepted subjective/psychological and objective/physiological outcomes are not well understood. Eligible patients (n = 80, 65 female, age: 49.3 ± 8.6 years) were enrolled and randomized into three intervention arms: (i) verum electro-acupuncture 'local' to the more affected hand; (ii) verum electro-acupuncture at 'distal' body sites, near the ankle contralesional to the more affected hand; and (iii) local sham electro-acupuncture using non-penetrating placebo needles. Acupuncture therapy was provided for 16 sessions over 8 weeks. Boston Carpal Tunnel Syndrome Questionnaire assessed pain and paraesthesia symptoms at baseline, following therapy and at 3-month follow-up. Nerve conduction studies assessing median nerve sensory latency and brain imaging data were acquired at baseline and following therapy. Functional magnetic resonance imaging assessed somatotopy in the primary somatosensory cortex using vibrotactile stimulation over three digits (2, 3 and 5). While all three acupuncture interventions reduced symptom severity, verum (local and distal) acupuncture was superior to sham in producing improvements in neurophysiological outcomes, both local to the wrist (i.e. median sensory nerve conduction latency) and in the brain (i.e. digit 2/3 cortical separation distance). Moreover, greater improvement in second/third interdigit cortical separation distance following verum acupuncture predicted sustained improvements in symptom severity at 3-month follow-up. We further explored potential differential mechanisms of local versus distal acupuncture using diffusion tensor imaging of white matter microstructure adjacent to the primary somatosensory cortex. Compared to healthy adults (n = 34, 28 female, 49.7 ± 9.9 years old), patients with carpal tunnel syndrome demonstrated increased fractional anisotropy in several regions and, for these regions we found that improvement in median nerve latency was associated with reduction of fractional anisotropy near (i) contralesional hand area following verum, but not sham, acupuncture; (ii) ipsilesional hand area following local, but not distal or sham, acupuncture; and (iii) ipsilesional leg area following distal, but not local or sham, acupuncture. As these primary somatosensory cortex subregions are distinctly targeted by local versus distal acupuncture electrostimulation, acupuncture at local versus distal sites may improve median nerve function at the wrist by somatotopically distinct neuroplasticity in the primary somatosensory cortex following therapy. Our study further suggests that improvements in primary somatosensory cortex somatotopy can predict long-term clinical outcomes for carpal tunnel syndrome.
Acute carpal tunnel syndrome is a progressive median nerve compression leading to loss of two-point discrimination. Most cases encountered are in the emergency department following wrist trauma and ...distal radius fractures. Although rare, atraumatic etiologies have been reported and diligent evaluation of these patients should be performed. If missed or neglected, irreversible damage to the median nerve may result. Once diagnosed, emergent carpal tunnel release should be performed. If performed in a timely manner outcomes are excellent, often with complete recovery.
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